Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require at least 
3 hours a day / 5 days a week, or 15 hours over 7 consecutive days, of therapy services.  It is not medically 
reasonable to expect you to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF at this time. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care 
provided from September 1, 2020, to December 5, 2020. 
 
You asked the Plan to waive the copayment for SNF care. You say that these services previously showed no 
copayment requirement. The Plan denied your request. The Plan says that this claim was processed correctly, 
and the copayment was assessed in accordance with the enrollees contract. The Plan also states that initially 
there was a processing error which caused the copayment to apply incorrectly at first. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $0 copayment for days 1-20 and a $100 copayment per day for days 21-100 per benefit period. A 
benefit period begins on the first day you go to a Medicare-covered inpatient hospital or skilled nursing facility. 
The benefit period ends when you havent been an inpatient at any hospital or SNF for 60 days in a row.  
The enrollee has been asked to pay $1,992.43 for a 96-day SNF admission. The record shows that the enrollee 
was not charged for the first 20 days of SNF care, was charged $1,000 for the next 10 days (10 x $100 = 
$1,000) and was charged $992.42 for all of the remaining days up to the 76th day requiring a copayment as 
they had met their out-of-pocket maximum at this time. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the skilled nursing facility (SNF) care provided from September 1, 2020, to December 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
gradient pressure appliance (E0673), provided on August 4, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered 
by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental gradient pressure appliance (E0673), provided 
on August 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 24, 2020, to April 28, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 689 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found DRG 690 (KIDNEY AND URINARY TRACT INFECTIONS WITHOUT 
MCC) was more appropriate in this case, as there is no documentation of a diagnosis of sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 24, 2020, to April 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 4, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the referring provider regarded this test as a 
medically necessary and valuable tool when determining the treatment for the enrollee. The Plan denied your 
request. The Plan says this provider is not a network provider with the Plan and the services were not referred 
by a network provider or rendered in an in-network facility. The Plan also says that they have also determined 
that these services are not urgent or emergent, nor were they 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 had network providers 
available who could have provided 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 laboratory services provided on August 4, 2021, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an orthovisc injection provided on 
October 6, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that the provider did not inform you of 
the higher charges. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for Part B drugs, including pain management drugs.  
 
 
 
 You have been asked to pay $571.31, which is 20% of the allowed amount for the injection ($2,856.53 allowed 
amount x 20% coinsurance = $571.31). The injection falls within the Medicare Part B Prescription Drugs 
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 coinsurance for an orthovisc injection provided 
on October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 11, 2021, 
through October 13, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that 
the medical record did not show that at the time of the inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care would span two midnights. The reasons for this conclusion 
are as follows: there was no evidence of ongoing bleeding or hemodynamic instability. Hemoglobin rose 
appropriately in response to the blood transfusion. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) on October 11, 2021, with rectal 
bleeding. She had documented rectal bleeding at the facility. Her Hgb was 4.7. She was evaluated and 
admitted. She was evaluated by Gastroenterology and underwent EGD colonoscopy/small bowel enteroscopy. 
A colonoscopy revealed an ulcer in the proximal rectum. She was transfused 3 units of packed red blood cells. 
Her condition stabilized and improved, and she was discharged back to the nursing facility when considered 
medically stable on October 13, 2021. The review has determined that the record showed that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollees necessary hospital care 
(including earlier ED 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from October 11, 2021, through October 13, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 4, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the copayment is to high for this 
service and the Plan should pay more then what it did. The Plan denied your request. The Plan says the proper 
copayment was applied for this service. 
 
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 $105 
copayment for Medicare-covered radiological diagnostic services.  
 
  You have been asked to pay a $105 copayment for an ultrasound. An ultrasound falls within Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 an ultrasound provided on October 4, 2021.
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 enrollee is stable and safe for 
discharge. You also say that an LTACH can render services that will improve the enrollee's condition, and 
avoid unnecessary hospital readmissions. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care and does not require transfer to a LTACH. 
 
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 LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. Our reviewer found that 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. Our physician reviewer also found that the requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 19, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
 
 
 The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). 
Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 
76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that 
the Plan does not have to pay for the abdominal ultrasound rendered on September 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Medicare Part B prescription drugs 
(J2001, J2704), provided on April 19, 2021. 
 
You asked the Plan to waive the copayment for the Medicare Part B prescription drugs. You say that the 
service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the Medicare Part B prescription drugs. This falls within 
the Medicare Part B prescription drugs 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 Medicare Part B prescription drugs (J2001, 
J2704), provided on April 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on July 14, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like payment to be 
processed for this claim. The Plan denied your request. The Plan says both the referring and rendering 
providers are non-participating with the Plan. The Plan also says that prior authorization was not obtained. 
 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 the physical therapy services provided on July 14, 
2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that that the member needs to continue her rehabilitation 
to strengthen her body so she can continue walking with her cane. The Plan denied your request. The Plan says 
that the enrollee can safely receive the services she needs in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
  
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a respiratory panel, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the laboratory services rendered on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480) provided on October 27, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a 
prior authorization, specifically for the member's plan type at the time of rendering services. The Plan denied 
your request. The Plan says this provider is not a network provider with the Plan, nor were the services referred 
by a network provider or rendered in a participating facility. The Plan also says that they have also determined 
that these services are not urgent or emergent, nor were they 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 had network providers 
available who could have provided 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 drug testing (G0480) provided on October 27, 
2021, by an out-of-network (OON) provider.