Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing provided on January 12, 2022. 
 
You asked the Plan to pay for COVID-19 testing. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  We find that CPT codes U0003 and U0005 have a Status Indicator of X on the Physician Fee Schedule. This 
means that CPT codes U0003 and U0005 are statutory exclusions. Based on this information, we decided that 
Medicare rules for coverage of COVID-19 testing have not been met. Therefore, we decided that the Plan does 
not have to pay for COVID-19 testing provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical epidural steroid injection (ESI). 
 
You asked the Plan to pay for a cervical ESI. You say that the enrollee is in pain and the requested services will 
improve her quality of life. The Plan denied your request. The Plan says the guidelines for coverage have not 
been met.  
The Plan follows Medicare rules. Medicare rules say that ESI services are covered when medically necessary 
for certain clinical indications. 
 
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 a cervical ESI. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has neck and left shoulder 
pain secondary to arthrosis of the facet joint in her neck that has not improved with medications, physical 
therapy, chiropractic care, or medial branch blocks. The enrollee does not have radiculopathy and/or 
neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative disc 
disease, producing foraminal or central spinal stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cervical ESI have not been met. Therefore, we decided that the Plan does not 
have to pay for a cervical epidural steroid injection (ESI).
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 the rehabilitation in order to function. The 
Plan denied your request. The Plan says you do not meet IRF criteria and it is not medically necessary. A lower 
level of care might be appropriate such as a skilled nursing facility, at home with supervision and home health 
services, in an assisted living facility with home health services, or in a long-term care facility with part-time 
skilled services. 
 
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 were admitted for encephalopathy. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. 
 
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 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 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 enrollee does not require the intensity of services provided at an IRF.  
 Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services with regular physician evaluation. The enrollees care needs can be met 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $26.06 coinsurance for an inpatient hospital stay from 
October 13, 2021, to October 29, 2021. 
 
You asked the Plan to waive the $26.06 coinsurance for an inpatient hospital stay. You say that you should not 
be responsible for this because you had to be admitted because of botched ER care. The Plan denied your 
request. The Plan says you are responsible for to pay a $26.06 coinsurance. 
 
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% 
coinsurance for Inpatient Hospital Care.  
 
You have been asked to pay a $26.06 coinsurance for inpatient hospital care. Inpatient hospital care falls within 
the Inpatient Hospital Care benefit category. At the time this claim was processed, you had not yet reached 
your maximum out-of-pocket. 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 $26.06 coinsurance for an inpatient 
hospital stay from October 13, 2021, to October 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF. You say that the enrollee needs SNF services. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing facility. 
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving care. All medically necessary care is being provided in the current acute care setting. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee. 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided from December 3, 2021, to 
December 6, 2021. 
 
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the criteria 
is not met. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee's symptoms began resolving on their own within the first day. Vitals 
were stable on admission. Our reviewer also found that there was no suggestion at the time of admission that 
the enrollee would require hospital services that would likely cross 2 midnights. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient admission provided from December 3, 2021, to December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on April 20, 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 are in a lot of pain and it appears you won't be at 
the facility for too long. The Plan denied your request. The Plan says the IRF services you are requesting 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 were admitted for a total hip replacement surgery. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While you have a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 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 the enrollee will clearly benefit from acute 
rehabilitation care to optimize a level of functioning prior to returning home. The enrollee has a serious, life 
threating constellation of acute medical problems that have left the enrollee at a functional status below 
baseline. The Plan denied your request. The Plan says the enrollee does not meet IRF criteria, is not medically 
necessary and needs may be met in current hospital 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 the enrollee was admitted for a stroke. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the enrollee has a need for physical or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on February 
5, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that your mother was hurt at the 
facility so they should pay the charges for transport. The Plan denied your request. The Plan says the 
copayment applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $290 copayment per date of service regardless of the number of trips.  
 
The enrollee has been asked to pay $290 copayment for ambulance transport. Ambulance transport falls within 
the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transport provided on February 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit, and 
inpatient stay provided on May 16, 2020, to May 27, 2020. 
 
You asked the Plan to waive the copayment for an emergency department visit and inpatient stay. You say that 
this is an old bill, and you should not have to pay this copayment. The Plan denied your request. The Plan says 
the copayment applied was 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 $310 per 
day copayment for an inpatient stay and an emergency care copayment of $90 for inpatient hospital stay and 
emergency services.  
 
You have been asked to pay $2260 total for an ER visit and inpatient hospital stay ($310 per day x 7 days =  
$2, 170 + $90 for ER visit = a total of $2, 260). 
 
 An emergency department (ER) visit and inpatient stay falls within the Inpatient Hospital Stay and Emergency 
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 an emergency department visit, and inpatient 
stay provided on May 16, 2020, to May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test (87811) purchased January 18, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 test. You say that the website says that you can be 
reimbursed for an at-home COVID-19 test kit on or after January 15, 2022. The Plan denied your request. The 
Plan says this item was not covered by the Plan at the time it was purchased. The Plan further states that the 
correct information is listed on the Plan's Medicare website. 
 
The Plan must follow Medicare rules. The Plan offers a supplemental benefit for at-home COVID tests that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan contract 
says that at-home COVID tests will be covered starting February 1, 2022. 
 
 
 We looked at the file and Medicare rules. In this case the at-home COVID-19 test kit was purchased prior to 
the effective date of the Plans coverage for this item. Based on this information, we decided that Medicare 
rules for coverage of the at-home COVID-19 test have not been met. Therefore, we decided that the Plan does 
not have to pay for the at-home COVID-19 test (87811) purchased January 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service February 9, 
2022. 
 
You asked the Plan to pay for procedure code 76882. You say that this service was billed appropriately and is 
supported in the medical record. The Plan denied your request. The Plan says payment for code 76882 is 
bundled into payment for code 93971. 
 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 76882 
is a column II code to column I code 93971. 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 76882 billed for date of service February 9, 
2022.