Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you 
received from January 7, 2019, through February 9, 2019. 
 
You asked the Plan to waive the copayment for the SNF services. You say that this bill is too high. The Plan 
denied your request. The Plan says you were charged this cost sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $172 
copayment per day for days 21-100 for skilled nursing facility care.  
 
Records show that you were in a SNF from October 22, 2018, through November 16, 2018, which is a total of 
25 days.  You were then readmitted to a SNF from January 7, 2019 through February 9, 2019, for a total of 33 
days. You have been asked to pay a $172 copayment per day for the SNF services in 2019 because you were 
still in the same benefit period as your previous SNF stay.  According to your Evidence of Coverage, a new 
benefit period does not start unless you have been out of the SNF for at least 60 days.  That was not the case 
here.  In this case, there was only a 52-day gap between the admission from October 22, 2018, through 
November 16, 2018, and the admission from January 7, 2019 through February 9, 2019. Since you were in the 
same benefit period, you were within the days 21-100 portion of your benefit period with regard to cost 
sharing.  That means the plan could charge you a $172 copayment for each day of the stay from January 7, 
2019 through February 9, 2019, (33 days x $172 per day = $5676).  Please note, however, that you hit your 
annual out-of-pocket maximum during this SNF stay, which is why the Plan has only charged you a total of 
$4843.  This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you 
received from January 7, 2019, through February 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on 
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
multiple infections in the setting of advanced Parkinson's disease. The enrollee was intubated/ventilated and 
subsequently received a tracheotomy.  The enrollee has since been weaned from the ventilator.  It is unclear if 
decannulation is planned.  There is no evidence that the enrollee requires services that are not currently 
available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute 
services are required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing 
long term care needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided on December 29, 2019. 
 
You asked the Plan to pay for the medical services. You say that the claim was submitted correctly. The Plan 
denied your request. The Plan says that the claim cannot be paid as submitted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There is no claim, NCCI document, or Medicare rule reference, in the case file. 
Therefore, we decided that the Plan has to pay for the medical services provided on December 29, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on May 16, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360 and NEXT-Generation) 
requires use of CPT 81479 (for the entire multi-test panel). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on May 13, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing enabled the enrollee's treating physician 
to determine the optimal treatment pathway for the enrollee. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service May 13, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for Guardant360 testing provided on May 13, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the treatment of an ankle fracture (27810) and emergency department 
visit (99285) provided on November 1, 2019. 
 
You asked the Plan to pay for the treatment of an ankle fracture and emergency department visit. You say that 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
that the documentation does not include the actual date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We find that CPT codes 27810 and 99285 are supported in the record. Specifically, the record reasonably 
indicates that these services were rendered on the billed date of service. Based on this information, we decided 
that Medicare rules for coverage of the treatment of an ankle fracture and emergency department visit have 
been met. Therefore, we decided that the Plan has to pay for the treatment of an ankle fracture (27810) and 
emergency department visit (99285) provided on November 1, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable after a hip fracture, and status post surgery. There is no 
documented evidence of medical issues that require monitoring by an inpatient rehab physician three times a 
week. The documentation does not support that there is a need for an intensive therapy program with 3 hours a 
day and an interdisciplinary approach to rehab care at the current functional status. You will not be able to 
make a significant functional recovery in a predicted period. Your rehab needs can be met in an alternate, less 
intense setting such as in a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on January 3, 2020, by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that the member's primary care physician did not refer these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab services provided on January 3, 2020, by an 
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on July 10, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on July 
10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to more than $125 for the eyewear you received on March 5, 2020. 
 
You asked the Plan to more than $125 for the eyewear. The Plan denied your request. The Plan says the benefit 
maximum has been paid. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $125 per calendar year. 
 
We looked at the file and the Plan's rules. The Plan paid $125 toward the eyewear in question. You are 
responsible for any amount over the $125 benefit limit. Therefore, we decided that the Plan does not have to 
more than $125 for the eyewear you received on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin and fish oil you received on May 13, 2020, and 
May 14, 2020. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says these drugs are not 
covered under your Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the insulin and fish oil you 
received on May 13, 2020, and May 14, 2020.  
 
Benefits for the drugs may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 7, 2020, and 
January 13, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive your care from a network provider. In most cases, care you receive from an out-of-network provider 
will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our 
network cannot provide this care, you can get this care from an out-of-network provider. You or your PCP 
must obtain authorization from the plan prior to seeking care 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on January 7, 2020, and January 
13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1851), suspension sleeve (L2397), and 
straight knee joint (L2385) provided on April 9, 2020. 
 
You asked the Plan to pay for a knee orthosis, suspension sleeve, and straight knee joint. You say that these 
items were medically necessary. The Plan denied your request. The Plan says there is not a valid proof of 
delivery for these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. While the file 
contains multiple shipping invoices and delivery tickets, none support both the billed items and billed date of 
service. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1851), suspension 
sleeve (L2397), and straight knee joint (L2385) provided on April 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telephone evaluation provided on April 
21, 2020. 
 
You asked the Plan to waive the copayment for a telephone evaluation. You say that you could not make a 
personal visit. The Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for Medicare-covered in-network specialist visits under the Essential plan.  
 
You have been asked to pay a $30 copayment for a telephone evaluation. A telephone evaluation falls within 
the physician/practitioner services, including doctor's office visits, benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a telephone evaluation provided on April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 test provided on October 31, 2019.
You asked the Plan to pay for the Guardant360 test. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says service providers should use one CPT code, not unbundle the test to
separate codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, we have confirmed that the Guardant360 test uses one code, 81479, and cannot be paid as billed.
This code cannot be paid as separate line items. Based on the claim submitted, Medicare billing criteria have
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 test provided on
October 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning at/near her baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on May 14, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this should be coded with CPT 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership fees provided January 17, 2019 to 
December 17, 2019. 
 
You asked the Plan to pay for the gym membership fees. You say that the fee's you paid are for your 
membership which are covered under your insurance plan. Please review and correct and reverse the decision 
for reimbursement. The Plan denied your request. The Plan says the plan does not cover this expense. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits 
only to a participating gym or fitness location for standard membership access at no additional cost. 
 
The Plan's rules for coverage of gym benefits have not been met because the you did not go through the Renew 
Active provider and did a Renew Active confirmation number for the 2019 year. Therefore, we decided that the 
Plan does not have to pay for the gym membership fees provided January 17, 2019 to December 17, 2019.