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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the documentation does not support a complex level of rehabilitation is 
reasonable and necessary in this case. 
 
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 documentation does not support that 
the enrollee requires and will tolerate at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive 
days, of therapy services. 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 lab services provided on August 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is a covered lab service and it was billed 
correctly. The Plan denied your request. The Plan says you provided the incorrect Place of Service code on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS). An independent laboratory taking a 
sample in its laboratory shows "81" as place of service. In this case, you have billed with a POS of 81, but the 
records do not indicate that your lab physically took the specimen from the enrollee.   Rather, it appears as though the specimen was taken from the enrollee at another location and the specimen was 
sent to you. In such cases, POS 81 should not be used on the claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on August 11, 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 documentation does not support that the enrollee requires at least 3 hours a day /5 day a week, or 15 hours over 7 consecutive days, of therapy services. The documentation supports those 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342), fluoride 
varnish application (D1206), and the delivery of antimicrobal agents (D4381) provided by a participating 
provider on October 1, 2021, and November 16, 2021. 
 
You asked the Plan to pay for periodontal scaling and root planing, fluoride varnish application, and the 
delivery of antimicrobal agents. You say that these services are medically necessary. The Plan denied your 
request. The Plan says the dental services that were provided are not covered benefits. 
 
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. 
 
 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing (D4342), fluoride varnish application (D1206), and the delivery of 
antimicrobal agents (D4381) provided by a participating provider on October 1, 2021, and November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the chemodenervation injection 
procedures you received at an outpatient hospital facility from July 31, 2019, to January 29, 2020. 
 
You asked the Plan to waive the copayments for the chemodenervation injection procedures. You say that you 
did not receive these injections in an operating room, so the copayments should not apply. The Plan denied 
your request. The Plan says you were charged these copayments correctly.  The Plan says that because the 
allowed amount for these services ($168.84) is less than your copayment obligation, you are responsible for the 
full allowed amount for each date of 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 $300 
copayment per visit for outpatient hospital services.   
You have been asked to pay a $300 copayment per visit for the chemodenervation injection procedures. You 
received these services at an outpatient hospital facility.  There is no requirement that an 'operating room' be 
used in order for this copayment to apply.  According to your contract, this copayment applies each time you 
visit an 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 waive the copayments for the 
chemodenervation injection procedures you received at an outpatient hospital facility from July 31, 2019, to 
January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 10, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee has a diagnosis of endometrial cancer. The review indicates that The 
F1Heme test is a proven medically necessary covered benefit for comprehensive genomic profile (CGP) testing 
for cancer to identify potential targeted therapy options in beneficiaries with a diagnosis of Acute Myeloid 
Leukemia (AML), Myelodysplastic Syndromes (MDS), Myelodysplastic Syndromes/Myeloproliferative 
Neoplasms (MDS/MPN), and Myeloproliferatlve Neoplasms (MPN). The review has determined that the items 
at issue in this case was not medically reasonable or necessary.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for a manual wheelchair provided to the enrollee on 
July 30, 2021 
 
You asked the Plan to pay for this equipment. You say that this equipment was medically necessary and should 
be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior 
authorization for this equipment. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that durable medical equipment requires prior authorization. The Plan did not pre-approve this manual 
wheelchair. We found no exception that would require the Plan to pay for this equipment. Therefore, we 
decided that the Plan does not have to pay for to pay for a manual wheelchair provided to the enrollee on July 
30, 2021
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided to the enrollee from July 3, 
2021 to July 5, 2021. 
 
You asked the Plan to pay for the services. You say that the services were provided in good faith. The Plan 
denied your request. The Plan says the provider was not active at this time, and the address is no longer active 
in the system. 
 
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 skilled nursing services provided to the enrollee 
from July 3, 2021 to July 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound of the arm and leg arteries 
provided on July 30, 2021. 
 
You asked the Plan to reduce the copayment for an ultrasound of the arm and leg arteries. You say that the 
technician told you that you were having a limited exam not a complete one. You also say there was a billing 
error. 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 $110 
copayment for in-network radiological diagnostic services, including ultrasounds.  
 
 The records show the Plan was billed code 93922, which is the limited study of upper or lower extremity 
arteries. You have been asked to pay a $110 copayment for an ultrasound of the arm and leg arteries. An 
ultrasound of the arm and leg arteries falls 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 reduce the copayment for an ultrasound of the arm 
and leg arteries provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (97813) and acupuncture, 
each additional 15 minutes (97814) provided August 18, 2021 
 You asked the Plan to pay for the acupuncture services. You say that you request that after review the medical 
records that all services be reprocessed and paid. The Plan denied your request. The Plan says services were 
rendered by a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the health Plan contract specifically says that the 
services must be provided by a legally qualified physician practicing within the scope of their license. The 
service was rendered by a licensed acupuncturist, not a physician. This provider is not supervised by a 
physician, PA, or NP/CNS. Therefore, we decided that the Plan does not have to pay for the acupuncture, initial 
15 minutes (97813) and acupuncture, each additional 15 minutes (97814) provided August 18, 2021
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the regadenoson injection you received on 
November 8, 2021. 
 
You asked the Plan to waive the coinsurance for the regadenoson injection. You say that you already paid a 
copayment on this date, so you don't understand why you still owe money. The Plan denied your request. The 
Plan says you were charged the copayment for the myocardial perfusion imaging you received on this date of 
service.  However, the Plan says that you were appropriately charged separate cost sharing for the drug you 
received. 
 
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 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the regadenoson injection. The regadenoson injection falls 
within the Medicare Part B 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 the regadenoson injection you received on 
November 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on September 7, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you believe the 
copayment should be waived due to your COVID-19 diagnosis. 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 $270 
copayment for each one-way trip.  
 
The file shows that the Plan unsuccessfully attempted to obtain medical records confirming the COVID-19 
diagnosis.  Therefore, you have been asked to pay a $270 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance Services 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 ambulance transportation services provided on September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was billed correctly and should be 
paid. The Plan denied your request. The Plan says you billed these services with the incorrect Place of Service 
(POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS). An independent laboratory taking a 
sample in its laboratory shows "81" as place of service. In this case, you have billed with a POS of 81, but the 
records do not indicate that your lab physically took the specimen from the enrollee.  Rather, it appears as though the specimen was taken from the enrollee at another location and the specimen was sent to you. In such 
cases, POS 81 should not be used on the claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on September 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Unna boot procedure (code 29580) 
provided on October 6, 2021. 
 
You asked the Plan to waive the copayment for an Unna boot procedure. You say that the claim was billed 
incorrectly. You also say that the procedure was for basic wound care not surgery. 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 $50 
copayment for in-network outpatient surgery at an outpatient hospital.  
 An Unna boot procedure is considered a surgical procedure for wound care. The medical records show that you 
did receive the procedure. You have been asked to pay a $50 copayment for an Unna boot procedure. An Unna 
boot procedure falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers 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 Unna boot procedure (code 29580) provided on October 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health services. You say that you do not want your home health aide 
services to expire. The Plan denied your request. The Plan says the enrollee does not require skilled care. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health services. Our reviewer 
says that the requested home health aide services are not medically necessary. Our physician reviewer found although the enrollee requires assistance with some activities of daily living records do not support the ongoing 
home health aide services beyond what have already been approved. The reviewer found that there are no 
medical notes from the enrollees treating physician are provided documenting an order or need for additional 
home health aide services. The reviewer found that the medical records provided there is no documentation that 
the home health aide services are reasonable and necessary to the treatment of the patients illness or injury by 
the skilled professional staff. Therefore, the reviewer found that the requested home health aide services are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Specifically, the file does not show 
that there are any medical notes from the enrollees treating physician documenting an order or need for 
additional home health aide services. Therefore, we decided that the Plan does not have to pre-approve home 
health aide services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on August 13, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that POS 81 is correct for these services. The 
Plan denied your request. The Plan says this was not billed with the appropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the member's face-to-face service was rendered in a laboratory 
setting. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on 
August 13, 2021.