Persius/hicric huggingface dataset:
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 the 
enrollee is with a past medical history of Parkinson's disease, hypertension and prostate cancer who initially 
presented to the acute hospital on 07/22/2020 with weakness, cough and fever. He has had a long complicated 
hospital course including treatment for bacteria and COVID-19 pneumonia and acute respiratory failure. He 
was treated in the hospital with intravenous antibiotics and he has required intubation and mechanical 
ventilation. He now has a tracheostomy tube and he has had issues with desaturations due to excessive tracheal 
secretions and he has had atrial fibrillation with rapid ventricular response. He has had a thoracic transverse 
myelitis and he has been treated with corticosteroids and neurology consultation. He is weak and deconditioned 
and has been evaluated by physical and occupational therapy. He is bed-bound and requires maximum 
assistance to sit up in bed. He is being fed by a percutaneous feeding tube. He does not appear to be medically 
stable to transfer to a lower level of care. 
 
The short-term acute care hospital can provide for all the enrollee's present inpatient care needs and the 
enrollee is receiving an appropriate level of care in the present setting. The short-term acute care hospital can 
provide for all the enrollee's present inpatient care needs. The enrollee is presently receiving these services in 
the short-term acute care setting. Continued care in the short-term acute care hospital is appropriate until the 
enrollee is stable to transfer to 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 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: 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 there is no 
documentation provided requiring admission to a LTACH. The enrollee still requires acute hospital level of 
care services and is receiving appropriate care at the present acute care hospital. The review has determined 
that the enrollee does not require services at the LTACH that are not available at the acute care hospital where 
she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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: 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 
a traumatic brain injury.  The enrollee was intubated/ventilated upon presentation and subsequently received a 
tracheotomy.  The enrollee is noted to be tolerating a tracheotomy collar.  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies (A4221, A4222) provided December 23, 
2019 to December 28, 2019. 
 
You asked the Plan to pay for the infusion supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the records did not include valid physician orders 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 physician order for the supplies provided in this case. 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 infusion supplies (A4221, A4222) provided December 23, 2019 
to December 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 provided on January 7, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD,
MALDI, TOF) includes sample validation when performed, per date of service.
We find that CPT code 80307 is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained
in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage
of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug
testing coded 80307 provided on January 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a PET scan (CPT 78815) provided to the enrollee on February 11, 2020.
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The Plan says PET procedures performed to inform the initial treatment strategy of tumors must be reported with an appropriate diagnosis.
The Plan must follow Medicare rules. Medicare rules say that PET scans are not covered for prostate cancer. The diagnosis in this case is malignant neoplasm of prostate. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pay for a PET scan (CPT 78815) provided to the enrollee on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 17, 2019 
to October 18, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the subsequent acute care hospital admission is considered to be 
included in the DRG from the initial admission. 
 
The Plan must follow Medicare rules. The rules say readmission review involves admissions to an acute, 
general, short-term hospital occurring less than 31 calendar days from the date of discharge. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found readmission occurred less than 48 hours from discharge, there were no new findings 
or complaints for the second admission to consider it separate from the first admission. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 17, 2019 to October 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided August 23, 2019 to
August 24, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the record did not show that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier emergency and/or
observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided August 23, 2019 to August 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service (A0428) provided 
on March 16, 2020. 
 
You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied 
correctly to the service provided. 
 
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 $220 
copayment for each one-way Medicare-covered ambulance trip.  
 
You have been asked to pay a $220 copayment for the one-way Medicare-covered ground ambulance trip 
provided. 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 the ambulance service (A0428) provided on 
March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telemedicine specialist office visit 
provided on April 27, 2020. 
 
You asked the Plan to waive the copayment for the telemedicine specialist office visit. You say that you should 
not be responsible for the copayment because you only spoke with the doctor for a few seconds. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $40 
copayment per specialist visit.  For this date of service, you have been asked to pay the allowed amount of the 
claim because this amount is less than the $40 copayment for the telemedicine specialist office visit.  
 
You have been asked to pay a $15 copayment for the telemedicine specialist office visit. The telemedicine 
specialist office visit falls within the Physician/Practitioner services, including doctors 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 the telemedicine specialist office visit provided 
on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 14, 2020. 
 
You asked the Plan to pay for a domiciliary, rest home visit. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 
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 a domiciliary, rest home visit provided on February 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the physical therapy visits provided from 
March 4, 2020 to March 11, 2020. 
 
You asked the Plan to reduce the copayments for the physical therapy visits. You say that you should only be 
charged a $10 copayment per visit. You say the therapy clinic is not a hospital. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $40 
copayment for physical therapy at an in-network outpatient hospital. 
 
You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy 
visits fall within the Outpatient rehabilitation services benefit category. The record shows you were billed by 
the outpatient hospital facility. 
 
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 reduce the copayments for the physical therapy visits provided from March 4, 2020 to 
March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on December 29, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you are the only provider who can provide 
these services in the nursing home. The Plan denied your request. The Plan says prior authorization was not 
obtained by the skilled nursing facility. 
 
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 
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 skilled nursing services provided on December 29, 
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wrist hand orthosis provided on March 17, 2020. 
 
You asked the Plan to pre-approve the wrist hand orthosis (L3916). You say that the orthosis was medically 
necessary. The Plan denied your request. The Plan says the physician listed confirmed he did not conduct a 
telehealth assessment or order this orthosis. 
 
The Plan must follow Medicare rules. Medicare requires that services provided/ordered/certified be 
authenticated by the persons responsible for the care of the enrollee in accordance with Medicare policies.  
You can find this in the Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking 
Corrective Actions, Section 3.3.2.4 entitled Signature Requirements. 
  
We looked at the file and Medicare rules. A review of the documentation shows invalid assessments and an 
invalid physician order. Based on this information, we decided that Medicare rules for coverage of the wrist 
hand orthosis (L3916) have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
wrist hand orthosis provided on March 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit, the EKG, and the echocardiogram provided from February 25, 2020 to March 18, 2020.
You asked the Plan to waive the copayments for the specialist office visit, the EKG, and the echocardiogram. You say that you should only be charged a $20 copayment for the echocardiogram and nothing for the EKG. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $35 copayment for services obtained from an in-network specialist, a $20 copayment in-network Medicare-covered non-radiological diagnostic services, and a $110 copayment for each in-network Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic).
You have been asked to pay a total of $160.23 for the specialist office visit, the EKG, and the echocardiogram. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The EKG and the echocardiogram fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
February 25, 2020
Specialist office visit
$96.47
$35.00
$35.00
February 25, 2020
EKG
$15.32
$20.00
$15.32
March 18, 2020
Echocardiogram
$181.87
$110.00
$110.00
Total
$160.23
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 copayments for the specialist office visit, the EKG, and the echocardiogram provided from February 25, 2020 to March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on October 28, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for 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 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 the enrollee by an out-of-network provider 
on October 28, 2019.