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 your current medical condition does not require intensive physician or nursing 
supervision in an IRF. You may benefit from additional physical and occupational therapy, but the 
documentation does not reveal your functional level requires this therapy must be on an intensive level in an 
IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON CT scan. You say that you were approved to have a second 
opinion with an OON provider at the requested facility. You say that this provider is requesting a CT scan be 
done to check the progress of your lung cancer after 3 months on treatment. The Plan denied your request. The 
Plan says there are several in-network radiology cites within Medicare's network adequacy for patients in King 
County where the enrollee can obtain this standard CT thorax. The Plan says that Radiology images can and are 
routinely sent to any facility. The Plan say that OON radiology services are not medically necessary. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
computed tomography (CT) to be provided 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. 
 
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 your current medical condition does not require intensive physician or nursing 
supervision in an IRF. The documentation does not reveal that your acute medical management has been 
completed. On March 3, 2022 you had elevated creatinine, reduced urine output and urinary retention. You 
were on NS IVF and were to have your renal function monitored. You may benefit from additional physical 
and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive 
level in an IRF or can be tolerated on an intensive level in an IRF. Therapy has been limited by fatigue and 
pain. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 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 Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and a segmental pneumatic 
appliance to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON pneumatic compressor and segmental pneumatic appliance. You 
say that it is medically necessary that the enrollee begin his compression therapy in the home. You say that the 
clinical documentation provided supports the need for the items in dispute. You say that your facility 
specializes in lymphedema therapy and that you are the enrollee's and the prescribing physician's preferred 
provider. The Plan denied your request. The Plan says medically necessary care is available in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor and a segmental pneumatic appliance to be provided 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. 
 
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 enrollee does not require at least 3 hours a day/5 days a week, or 15 hours over 7 
consecutive days, of therapy services at this time. Skilled therapy services may 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery of neuropsychological testing. 
 
You asked the Plan to pre-approve the neuropsychological testing. You say that you believe that this is 
necessary to assess your condition. The Plan denied your request. The Plan says criteria for coverage of this 
testing are not met in this case. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is intended to diagnose 
and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. 
There are various signs/symptoms which would warrant such testing 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 the neuropsychological testing. Our 
reviewer says that the documentation does not support that LCD criteria are met for medically necessary 
testing. Our physician reviewer found the provided medical records do not describe the nature and extent of the 
enrollee's neuropsychological signs, symptoms or diagnosis. The records do not describe what evaluation has 
taken place already with regard to his neuropsychological issues and why the requested testing is now 
medically necessary. Records do not describe how the results of the testing will affect the enrollee's treatment 
plan.  
 
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 neuropsychological testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a battery of neuropsychological testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 29, 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 outpatient hospital setting and 
should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on June 29, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to reduce the cost sharing for the inpatient hospital stay provided from July 25, 
2021, to July 29, 2021. 
 
You asked the Plan to reduce the cost sharing for the inpatient hospital stay. You say that the enrollee was on 
vacation and needed medical attention. You also say that this was a medical emergency, and out of network 
should not apply. The Plan denied your request. The Plan says that the enrollee was stabilized and the out of 
network cost sharing applied. The Plan says that the enrollee has been charged the correct cost sharing amount. 
 
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. The Plan did not submit medical records showing the enrollees condition was 
not, or was no longer, an emergency. Therefore, the Plan cannot cover the service at the out of network rate. 
 
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 says that the doctors who give you emergency care are the ones who decide when you are stable, and the medical emergency is over. The 
contract also says that enrollees must pay a $200 copayment per day, for days 1-5, for in-network inpatient 
hospital care. 
 
The Plan says the enrollee must pay 30% coinsurance for the inpatient hospital stay for an out of network 
hospital. Based on the plan contract, however, the enrollee cannot be asked to pay more than the $200 per day 
copayment for an in-network inpatient hospital stay. We decided that the Plan has to reduce the cost sharing for 
the inpatient hospital stay provided from July 25, 2021, to July 29, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you more for a COVID-19 antigen laboratory test 
provided on August 31, 2021. 
 
You asked the Plan to reimburse you more for the COVID-19 antigen laboratory test. You say that the services 
should be covered in full. The Plan denied your request. The Plan says the claim processed correctly and you 
were reimbursed the correct amount based on the allowed amount and Plan's contract. 
 
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 50% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 You have been asked to pay the remaining amount for the COVID-19 antigen laboratory test. Per your contract 
with the Plan, 50% of the allowed amount is reimbursed for out-of-network laboratory services.  COVID-19 
antigen laboratory tests fall within the 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 reimburse you more for a COVID-19 antigen laboratory test provided on 
August 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infliximab (Remicade) injections provided 
from June 1, 2021, to August 30, 2021. 
 
You asked the Plan to waive the coinsurance for the injections. You say that the drug should not cost anything 
since the enrollee is part of a patient assistance program. 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). The enrollees contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Part B drugs.  
 
Drug Allowed Amount 20% Coinsurance 
Remicade  June 1, 2021 $2,517.12 $503.42 
Remicade  August 30, 2021 $2,479.14 $495.82 
Total:  $999.24 
 
The enrollee has been asked to pay $999.24, which is 20% of the allowed amount for the injections. The 
injections fall within the Medicare Part B Prescription Drugs benefit category. 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 coinsurance for infliximab (Remicade) injections provided from June 1, 2021, to August 30, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 30, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you feel that the POS coding rules cited by 
the Plan do not apply to services covered under the Clinical Laboratory Fee Schedule (CLFS). The Plan denied 
your request. The Plan says this was not billed with the proper POS code. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. We do not find evidence that these rules would not apply to services 
paid on the CLFS. The documentation does not indicate this sample was taken by the lab directly. As such, the 
use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on June 30, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's medical and therapy needs could be met in a skilled nursing unit. 
 
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 the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy, occupational therapy, or an 
intensive rehabilitation program. There is no reasonable expectation that the enrollee would be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), extractions (D7140), 
x-rays (D0210), implant removals (D6100), custom fabricated abutment (D6057) and cleaning and inspection 
of removable denture (D9932) provided from July 15, 2020, to August 8, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were told by your providers that these 
services would be covered under your medical insurance. The Plan denied your request. The Plan says the 
rendered services are dental in nature and are not eligible for coverage under your medical insurance. You are 
responsible for the cost of any dental care that exceeds the Plan's $500 annual limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers up to $500 
every year for non-Medicare covered preventative dental services and non-Medicare covered comprehensive dental services combined. 
 
Although these services were recommended by a physician, these services were not surgery of the jaw or 
related structures, setting fractures of the jaw or facial bones, or extraction of teeth to prepare the jaw for 
radiation treatments. The services at issue are purely dental in nature and involved the care, treatment, filing, 
removal or replacement of teeth or structures directly supporting the teeth. This means that these services are 
not eligible for coverage under Original Medicare or your medical benefits. Though the Plan offers a dental 
benefit in excess of Medicare coverage, the requested items or services were provided in excess of the Plans 
$500 annual allowance for supplemental dental care. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral exam (D0150), extractions (D7140), x-rays (D0210), implant removals (D6100), 
custom fabricated abutment (D6057) and cleaning and inspection of removable denture (D9932) provided from 
July 15, 2020, to August 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 25, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you feel that the POS rules cited by the 
Plan only apply to lab tests paid on the Physician Fee Schedule (PFS) and that using POS 81 is correct for this 
testing. The Plan denied your request. The Plan says this was not billed with the proper POS code based on 
where the services took place. 
 
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on June 25, 2021.