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

 
We decided that the Plan has to waive the copayment for a skilled nursing facility (SNF) stay from March 1, 
2022, to March 18, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you are appealing because you find it 
too much of a copayment and you feel your insurance should have covered all of it. The Plan denied your 
request. The Plan says that the cost sharing was applied correctly. 
 
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 says you had a previous SNF stay from February 15, 2022, to February 28, 2022, which would use 13 
days of this benefit period. However, the Plan did not forward information to support their claim of a previous 
SNF stay. Without this information we are unable to confirm the cost sharing was applied correctly. It is the 
burden of the Health Plan to substantiate their decision with evidence. In this case, the Plan has not submitted 
sufficient evidence to substantiate their decision so we must find in your favor.  
  
Therefore, we decided that the Plan has to waive the copayment for a skilled nursing facility (SNF) stay from 
March 1, 2022, to March 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 3, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 
0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 3, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81355, 81335, 81401, 0031U, 0032U, and 0033U.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75822 and 75825 billed for date of service 
July 21, 2022. 
 
You asked the Plan to pay for procedure codes 75822 and 75825. The Plan denied your request. The Plan says 
payment for codes 75822 and 75825 are bundled into payment for code 37238.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
75822 and 75825 are column II codes to column I code 37238. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 75822 
and 75825 billed for date of service July 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional hours per day, five days per week, of home 
health aide (HHA) services. 
 
You asked the Plan to pre-approve additional hours of HHA services. The Plan denied your request. The Plan 
says the additional hours requested is considered custodial care and personal care instead of a medical need. 
The Plan also says for this reason, this request is denied because it is not considered medically necessary. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional hours of HHA services. Our 
reviewer says that additional hours of HHA services are not reasonable and necessary. Our physician reviewer 
found the clinical documentation does not show any change in treatment plan, clinical, or functional status, thus 
additional home health aide service (8hrs per day, 5 days per week) is 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 additional hours of HHA services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional hours per day, five days per week, of home health aide 
(HHA) services.
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 it is felt that IRF care would be best for this 
enrollee's recovery. The Plan denied your request. The Plan says this level of care is not medically indicated. 
 
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 was admitted to the hospital on November 14, 2022, with acute 
respiratory failure due to bacterial pneumonia. He also underwent a hip replacement on November 1 and had a COVID-19 infection on November 11. He has been medically stabilized and has debility with decreased 
function. There is no clear need for close physical medicine physician supervision for ongoing medical 
management. At the current level of function, the enrollee does not need 3 hours a day, 5 days a week of 
therapies with multidisciplinary approach in an IRF. While the enrollee would benefit from additional therapy, 
the enrollee's rehab needs can be safely provided in an alternate and low intensity setting. 
 
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: 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the 
requirements for approval. 
 
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 that the enrollee is medically stable and does not need physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. At the current functional level, the enrollee 
does not need 3 hours a day for 5 days a week of therapies with multidisciplinary approach in an IRF. The 
enrollee needs rehabilitation in a lower intensity setting. The documentation does not support medical necessity 
for admission to an IRF due to lack of medical complexity and lack of nursing needs. While the enrollee would 
benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely 
provided in an alternate and low intensity setting. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for continuous positive airway pressure 
(CPAP) accessories on April 5, 2022. 
 
You asked the Plan to waive the copayment for continuous positive airway pressure (CPAP) accessories. You 
say that you would like to appeal the cost share. The Plan denied your request. The Plan says this cost sharing 
was charged 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 and a $450 deductible for continuous positive airway pressure (CPAP) accessories.  
 
You have been asked to pay a 20% coinsurance and a $450 deductible for continuous positive airway pressure 
(CPAP) accessories. This item/service falls within the Durable medical equipment (DME) and related 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 continuous positive airway 
pressure (CPAP) accessories on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tinted lenses. 
 
You asked the Plan to pre-approve the hearing aids. You say that it is medically necessary to have transition 
lenses due to your diagnosis of photophobia. The Plan denied your request. The Plan says the tinted lenses are 
not medically necessary. 
 
 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 tinted lenses. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the record shows the provider's letter is 
from 2018 and there is no documentation of a more recent evaluation or eye exam.  There is no documentation 
that the patient has tried and failed sunglasses or clip on sunglasses.  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the tinted lenses have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the tinted lenses.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that based on his current condition, functional deficits 
and multiple comorbidities, the attending physicians determined he meets the full inpatient acute rehab criteria. 
You say that his needs cannot adequately be met by skilled nursing or home health at this time. The Plan 
denied your request. The Plan says the requested admission to an IRF is medically necessary. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay. The enrollee does not require rehab services 15 hours a week 
under the supervision of a physician. Further services can be received 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take-home supply of Methadone (G2078) and medication 
assisted treatment with Methadone (G2067) provided on March 28, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the outpatient services. You say that this is an opioid treatment program (OTP) 
clinic. You also say that no authorization is required for Federally Qualified Health Center (FQHC) tribal OTP 
facilities. The Plan denied your request. The Plan says 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 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 the take-home supply of Methadone (G2078) and medication assisted 
treatment with Methadone (G2067) provided on March 28, 2022, 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 you need IRF care to get stronger before returning 
home. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services 
do not meet the requirements for approval. 
 
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 you are medically stable and do not need physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. At your current functional level, you do not need 3 hours a 
day for 5 days a week of therapies with multidisciplinary approach in an IRF. The documentation does not 
support medical necessity for admission to an IRF due to lack of medical complexity and lack of nursing needs 
and current high functional level. While you would benefit from physical therapy and occupational therapy, 
your rehab needs can be safely provided in an alternate and low intensity setting. 
 
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: 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 needs LTACH care. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not 
meet the requirements for approval. 
 
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 that in this case the enrollee was admitted with lower extremity cellulitis and 
osteomyelitis. The record indicates that the enrollee is improving but still require acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services and these have not 
been denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied.  The requested service cannot be recommended. 
 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 targeted genomic sequence analysis panel, 5-50 genes 
(81450) provided January 17, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please reprocess with the additional medical 
records attached, identifying medical necessity. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Specifically, the documentation submitted does not include a 
valid signature from the persons responsible for the care of the beneficiary. outreach by the Plan was made to 
the office of the ordering provider indicated confirmed that the genetic testing order was not made by this 
provider for January 2022. There was genetic testing ordered buy that was back in 2017, which is 5 years ago. 
Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, 5-
50 genes (81450) provided January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 24, 2021, billed with 
codes 81479, 81408, 81407, 81406, 81405, 81404, 81403 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that this panel was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. In 
addition, this test is a screening which is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 24, 2021, billed with codes 81479, 81408, 81407, 81406, 81405, 81404, 81403 and 81401.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88341, 88342, 88360, 88381) provided 
on March 16, 2022. 
 
You asked the Plan to pay for pathology services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the technical 
component (TC) of a physician pathology service provided to an inpatient or outpatient. 
 
We looked at the file and Medicare rules. The record indicates the pathology services at issue were provided to 
a hospital outpatient, but these services were not billed with a modifier indicating only the professional 
component, not the technical component, is being billed. Based on this information, we decided that Medicare 
rules for coverage of pathology services have not been met. Therefore, we decided that the Plan does not have 
to pay for pathology services (88341, 88342, 88360, 88381) provided on March 16, 2022.