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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
September 1, 2021, to September 22, 2021. 
 
You asked the Plan to pay for SNF care. You say that these services should be covered at the in-network rate as 
you did not have a choice in which facility you received skilled nursing care. The Plan denied your request. 
The Plan says these services were not provided directly by the Plan or through arrangements made by the Plan. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided from September 1, 2021, to September 22, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health visits provided on December 17, 
2021, to January 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health visits. The Plan denied your request. The Plan says 
the services were provided out-of-network and were not 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 the outpatient mental health visits provided on 
December 17, 2021, to January 24, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on April 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that the services provided should be covered under the 
authorization number that the facility received. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not 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 the eye exam provided on April 29, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on April 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that the doctor's office failed to send in a 
preauthorization form for approval. The Plan denied your request. The Plan says the ordering physician and 
provider are out-of-network, and the services were not 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 the lab testing provided on April 22, 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 continuing rehab services. The Plan denied 
your request. The Plan says that your therapy needs can be provided at a lower level of care. 
 
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 your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain his functional status. You can receive further services at a 
lower level of care. Our physician reviewer found that your 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services (80053) provided on 
February 23, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that these services were provided 
as part of your annual wellness visit and you were under the impression there would be no copayment. The 
Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed 
in accordance with your 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 $10 
copayment for Medicare-covered laboratory tests.  
 
You have been asked to pay a $10 copayment for laboratory services. 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 laboratory services (80053) provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Integrated BRAC Analysis genetic testing (81162). You asked the Plan to pre-approve genetic testing. You say that you have lost family members to cancer, and 
this test is medically necessary and important. The Plan denied your request. The Plan says you do not have a 
personal history of cancer; therefore, the criteria for coverage of this testing are not met. Testing for these 
genes is intended for those who already have a cancer diagnosis and is not covered as a screening. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier.  
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Integrated BRAC Analysis genetic testing (81162).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely 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 your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. You continue to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that you would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status. You can receive further services at a lower level of care. Our physician reviewer 
found that your 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on November 22, 
2021, to November 30, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
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 $240 
copayment per day for days 17 of a hospital stay for Alameda, Napa, and San Francisco counties, Contra 
Costa County Enhanced, Santa Clara County Enhanced, or Santa Cruz County plan members for inpatient 
hospital stay. For days 1-7, there is a $240 copayment. $240 x 7 = $1,680. Therefore, results in the total cost 
sharing amount of $1,680.  
 
 You have been asked to pay a $240 copayment per day for inpatient hospital stay. Inpatient hospital stay falls 
within the Inpatient hospital care 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 
inpatient hospital stay on November 22, 2021, to November 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan (93971) provided on 
February 1, 2022. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that you feel you should not be 
responsible for this cost share amount, and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received a duplex scan on the date of service at issue in this appeal. The Plan 
says that the correct copayment has applied per your contract with the Plan. 
 
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 Outpatient Diagnostic Tests.  
 
You have been asked to pay $108.25 for the duplex scan, which is less that the contracted $110 copayment 
amount. The duplex scan falls within the Outpatient Diagnostic Tests 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 duplex scan (93971) provided on February 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on June 2, 2022. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 had network providers available who could have provided the services at issue in this appeal. The 
Plan did not pre-approve the 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 physician services provided 
to the enrollee on June 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service February 
10, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the claim at issue does not contain a unique test 
identifier for the services at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that all MDT services must include an identifier as 
additional claim documentation. 
 
We looked at the file and Medicare rules. In this case, the claim for the services at issue was not submitted with 
a unique test identifier. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) 
billed for date of service February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure 
(CPAP) machine and supplies provided on January 28, 2022, February 28, 2022, March 28, 2022, and April 28, 
2022. 
 
You asked the Plan to waive the coinsurance for the CPAP machine and supplies. You say that the machine 
should not be billed or charged. The Plan denied your request. The Plan says the proper coinsurance was 
charged since the 5-year reasonable useful lifetime for the prior oxygen equipment was not met. 
 
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-covered durable medical equipment (DME) items and certain drugs. For each date of 
service, the total amount charged was $51.63 with a coinsurance amount of $10.33 ($51.63 total amount x 20% 
coinsurance amount). The total coinsurance amount for the 4 dates of service was $41.32 (4 dates x $10.33 
coinsurance). 
 
  You have been asked to pay a $41.32 coinsurance for the CPAP machine and supplies. The CPAP machine and 
supplies 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 coinsurance for a continuous positive airway pressure (CPAP) machine and 
supplies provided on January 28, 2022, February 28, 2022, March 28, 2022, and April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on January 19, 2022. 
 You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the provider did 
not submit authenticated records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, the billed services were not supported. There are no 
medical records to show the results of the testing. There are no records from the treating provider to show the 
intent for the services at issue to be provided. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
services provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided the Plan does not have to pay for drug testing provided to the enrollee and billed under code 
83789. 
 
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan 
denied your request. The Plan says code 83789 represents a not elsewhere specified code. However, a 
complete description of the not elsewhere specified code was not included. The lab requisition must include 
what laboratory test was requested in order to validate the not elsewhere specified code billed. The medical 
records provided indicate that the urine specimen was collected for drug testing. When specimen validity 
testing is conducted as part of drug testing, it cannot be billed separately. It is noted that multiple 
attempts were made to contact the provider for additional information. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted was not coded 
appropriately based on the medical records provided. Medicare rules for coverage of this testing have not been 
met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee and 
billed under code 83789.
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 May 
20, 2021, to May 24, 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 the DRG was downgraded from 698 to 699 in this case.  
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 698. 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 that the review has determined that DRG 698: 
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC was not appropriate. DRG 
699:OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC is the appropriate DRG. He 
remained hemodynamically stable and was discharged home on 05/24/2022. There was no clinical evidence 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 May 20, 2021, to May 24, 2021.