Persius/hicric huggingface dataset:
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 the enrollee can benefit from an IRF to improve 
overall safety and functional mobility prior to returning home with family. You say that the enrollee is at high 
risk for falling and infection. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee can receive the care they need in another setting. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing on 8-14 classes of drugs (G0481) provided on 
March 3, 2022. 
 
You asked the Plan to pay for drug testing on 8-14 classes of drugs. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the number of drug classes for which the enrollee was 
tested on this date is less than the number of drug classes billed. 
 
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, the CPT Code Manual definition of code G0481 is drug testing, 8-14 classes of drugs. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the records do not show that 
8-14 classes of drugs were tested.  Based on this information, we decided that Medicare rules for coverage of 
drug testing on 8-14 classes of drugs have not been met. Therefore, we decided that the Plan does not have to 
pay for drug testing on 8-14 classes of drugs (G0481) provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on February 03, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee may obtain services from out-of-network providers for emergencies 
and urgently needed care when the network is not available (generally, when you are out of the area), out -of-
area dialysis services, and when you have authorization to obtain specialized services that are not available in 
network. To obtain authorization, the enrollees primary care provider (PCP) must first refer the enrollee to the 
out-of-network provider and then request approval from the plan before they receive the services. 
 
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 genetic testing provided on February 03, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on October 19, 
2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were not aware of a 
coinsurance. 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 for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for an injection. The total allowed amount is $537.36. The total 
amount you are being asked to pay is ($537.36 x 20% = 107.47). However, you are being asked to pay $104.40 
which is less than the required amount. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an 
injection provided on October 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve more than 50 one-way routine transportation trips. 
 
You asked the Plan to pre-approve more than 50 one-way routine transportation trips. You say that you were 
diagnosed with cancer and need rides available for radiation and chemotherapy. The Plan denied your request. 
The Plan says the number of trips requested is beyond the number of trips covered in the 2022 transportation 
benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way routine transportation trips. 
 We looked at your request, the records in the case file, and the rules. The case file shows that, at the time of 
your authorization request, you had used 26 one-way routine transportation trips. This means that 24 one-way 
routine transportation trips remained of your benefit. Based on this information, we decided that the number of 
one-way routine transportation trips being requested exceeds the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve more than 50 one-way routine 
transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at home coronavirus (COVID-19) test purchased on 
December 24, 2021. 
 
You asked the Plan to pay for an at home coronavirus (COVID-19) test. You say that you purchased these tests 
only three weeks before the "required" federal January 15, 2022, start date. The Plan denied your request. The 
Plan says per the Centers for Medicare and Medicaid Services (CMS), plans or issuers may, but are not 
required by federal law to provide such coverage for over-the-counter at-home COVID-19 tests. The Plan also 
says that per the EOC, if the member gets services that are excluded (not covered), the member must pay for 
the services themselves. 
 
  The Plan must follow Medicare rules. Medicare rules say that starting January 15, 2022, most people with a 
health Plan can go online, or to a pharmacy or store to purchase an at-home over-the-counter COVID-19 
diagnostic test authorized by the U.S. Food and Drug Administration (FDA) at no cost, either through 
reimbursement or free of charge through their insurance.  
 
We looked at the file and Medicare rules. The record shows the COVID-19 tests were purchased prior to 
January 15, 2022. Based on this information, we decided that Medicare rules for coverage of an at home 
coronavirus (COVID-19) test have not been met. Therefore, we decided that the Plan does not have to pay for 
an at home coronavirus (COVID-19) test purchased on December 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for colonoscopy provided on April 14, 2022. 
 
You asked the Plan to waive the deductible for colonoscopy. You say that this should be covered. 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 $750 
deductible for Outpatient surgery. 
 
You have been asked to pay a $750 deductible for colonoscopy. This item/service falls within the Outpatient 
surgery 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 deductible for colonoscopy provided on 
April 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 24, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 70450 billed for date of service June 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the 
enrollee approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 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 home health services provided on May 26, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires close physician oversight at an 
IRF. You say that the enrollee requires this level of care to increase their functional mobility and to ensure 
medical stability prior to them going back home. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, the enrollee's needs can be met 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. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a twelve (12) month rental of an oxygen concentrator 
(E1390) and a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve oxygen equipment. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee has had equipment for 3 years and has not reached the 5-year 
period for a new rental agreement. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime for oxygen 
equipment is 5 years. 
 
We looked at the file and Medicare rules. The records show that the enrollee has had oxygen equipment since 
September 9, 2019. The enrollee remains under the 3760 month period for continued service and has not 
reached the 5 year period for a new rental. Based on this information, we decided that Medicare rules for 
coverage of oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pre-
approve a twelve (12) month rental of an oxygen concentrator (E1390) and a portable oxygen concentrator 
(E1392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve surgery 
services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound cleansing and durable medical equipment provided 
on June 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a wound cleansing and durable medical equipment. You say that you are 
contracted with this facility and have no control over facility staff submitting paperwork. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld.  
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 a wound cleansing and durable medical equipment 
provided on June 6, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee had not health plan coverage as of 10/31/22. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that the enrollee had a 
normal neuro exam but does have a history of prior lumbar surgery. According to the requesting physician, the 
enrollee has had six weeks of physical therapy without relief. The criteria for the requested MRI of the lumbar 
spine are thus satisfied and the exam should be approved. 
 
The original request for this case on September 13, 2022. The enrollee's coverage with the plan termed on 
10/31/22, so the case must be worked as normal. 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 MRI have been met. 
Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extremity brace to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve extremity brace. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says it is important to know which providers are part of our network because, 
with limited exceptions, while the enrollee is a member of our plan the enrollee must use network providers to 
get their medical care and services. 
 
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 
extremity brace to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on April 15, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that this should be covered. 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 $10 
copayment for Primary care provider visits for Medicare-covered services. 
 
You have been asked to pay a $10 copayment for office visit. This item/service falls within the Primary care 
provider visits for Medicare-covered 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 office visit provided on April 15, 2022.
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 LTACH care is medically reasonable for 
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 the patient appears to still be somewhat unstable (feeding source, vent, infection, 
anemia) but improving and should only require short-term additional acute care services that can safely be 
provided at the current facility until more stable and appropriate for a lower level of care. The patient does not 
require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is 
not medically necessary as the patient is not yet stable and as it would not be clinically advantageous at this 
time. Completion of treatment at the current facility is 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.