Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is of great concern that you be in a place to heal 
before an upcoming surgery. The Plan denied your request. The Plan says the criteria for IRF admission have 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
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 IRF. 
 
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: Partially Favorable

 
We decided that the Plan has to pay for one unit of code 87640. We decided that the Plan does not have to pay 
for the second unit of 87640.  
 
You asked the Plan to pay for the testing as billed. You say that this testing should be paid in full. The Plan 
says that this was originally denied due to a maximum number of units edit; however, it was found this is 
screening testing. 
 
We decided that the Plan has to pay for one unit of code 87640.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
This testing was ordered by a network provider. Therefore, we decided that the Plan has to pay for one unit of 
code 87640. The file does not show that the plan provided notice that the testing would not be covered. The file 
clearly shows that the services were rendered. Under Medicare rules, this means the testing is considered 
approved by the plan. 
 
We also decided that the Plan does not have to pay for the second unit of 87640. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file does not support that two tests for this pathogen were performed on this date of service. As such, the 
second unit is not payable. Therefore, we decided that the Plan does not have to pay for the second unit of 
87640. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the SNF stay should be approved. The Plan 
denied your request. The Plan says you do not meet the CMS criteria for skilled nursing level of care. 
 
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 the SNF services. Our reviewer says 
that you do not qualify for SNF coverage. Our physician reviewer found that you do not have documented 
skilled nursing needs or skilled therapy needs. Your care needs can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) 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 LTACH care is medically reasonable 
and necessary. 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 is an 82-year-old female who was admitted to the acute care hospital 
with rectal bleeding and acute myeloid leukemia complicated by acute kidney failure, malnourishment, 
pneumonia, and mental status changes, treated with hemodialysis, transfusion, antibiotics. Recent notes 
describe the patient as tolerating dialysis and physical therapy/occupational therapy, Boost and regular diet, 
with improving mental status. The patient appears to be stable and improving and should only require short-
term additional acute care services that can be safely completed at the current facility until 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 an LTACH is not medically necessary as it would not be clinically advantageous. 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac genetic testing services provided on July 29, 
2021. 
 
You asked the Plan to pay for the cardiac genetic testing services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the cardiovascular 
screening/risk assessment panel was denied for not meeting Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the cardiac genetic testing services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that issue is whether the requested genetic testing is medically appropriate 
and necessary. The test is described as a genetic based cardiovascular risk factor screening test in which 
multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the presence of 
pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac risk. It is not a 
diagnostic test. There is no evidence to support its role in this patient clinical management. In summary, the 
requested testing is not considered reasonable or 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 the cardiac genetic testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the cardiac genetic testing services provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the  x-rays provided on February 7, 2022. 
 
You asked the Plan to waive the copayments for the x-rays. You say that you don't understand why your being 
charged three separate copays. You feel this should be covered since it was at the office visit. The Plan denied 
your request. The Plan says the copayments applied are 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 $15 
copayment for each Medicare-covered standard x-ray service. 
 
You have been asked to pay a total of $45 for the x-rays ($15 per x-ray x 3= $45). X-rays fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the  x-rays provided on February 7, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
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 you 
meet the Medicare criteria for SNF care. Our physician reviewer found you do not have documented skilled 
nursing needs. You do have documented skilled therapy needs. You appear to be functioning below your 
baseline. The documentation does not yet establish that you have reached a new, lower, level of function. A 
period of daily skilled services is reasonably required to establish a maintenance program and/or to prevent 
deterioration of your condition. As a practical matter, you cannot receive services at home. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from January 3, 2022, to January 27, 2022. 
 
You asked the Plan to waive the copayments for the PT services. You say that you needed therapy for COVID -
19 recovery. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each therapy visit at an outpatient hospital.  
 
The Plans COVID-19 treatment cost share waivers only apply to active, confirmed cases. Therefore, you have 
been asked to pay a $35 copayment for each visit for the PT services. The file shows a total of 7 visits from 
January 3, 2022, to January 27, 2022, for a total of $245 ($35 copayment x 7 visits = $245). The PT services 
fall within the Outpatient Rehabilitation 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 copayments for physical therapy (PT) services 
provided from January 3, 2022, to January 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the abdomen provided on 
February 16, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you thought the test was included 
with your annual exam. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment per day for ultrasounds.  
 
You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an ultrasound of the abdomen provided on February 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided July 8, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that this service should be covered because it 
was a medical emergency. The Plan denied your request. The Plan says this service is not covered because 
there was not transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on July 8, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided July 8, 2021.
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 necessary 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 is a 67-year-old female who was admitted to the acute care hospital 
with pneumoperitoneum, sepsis, atrial fibrillation with rapid ventricular rate, and supraventricular tachycardia, 
complicated by acute respiratory failure and requiring mechanical ventilation support, tracheostomy, wound 
care, vasopressors, and antibiotics. Recent notes describe the patient as tolerating trach collar during the day 
and vent support at night but is having recurrence of fevers. Antibiotics were restarted. The patient appears to 
have been improving but requires additional short-term acute care services that can be safely completed 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 LTACH is not medically necessary due to instability and as it would not be clinically advantageous. 
Completion of treatment at the current facility is recommended in this case. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive your coinsurance for a CPM exercise device provided from 
February 8, 2022, to February 23, 2022. 
 
You asked the Plan to waive your coinsurance for a CPM exercise device. You say that the rental for the CPM 
device is free for days 0 through 20. The Plan denied your request. The Plan says you must pay a 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. 
 
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 Durable Medical Equipment (DME) And Related Supplies.  
 
 
 
 
You have been asked to pay a 20% coinsurance for a CPM exercise device. A CPM exercise device 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 your coinsurance for a CPM exercise device provided from February 8, 2022, to February 23, 2022.  
 
Please note: in your appeal you indicated you have a written statement that says the DME rental of the CPM device is 
free for days 0 through 21. A copy of this written statement was not received and could not, therefore, be considered 
when making this determination.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $10 copayment for laboratory services performed on 
December 30, 2021.  
 
You asked the Plan to waive your $10 copayment for laboratory services performed on December 30, 2021. 
You say that the service should be covered because it was done as part of your annual physical. The Plan 
denied your request. The Plan says you must pay a $10 copayment per day for other laboratory tests that are not 
fecal immunochemical (FIT) tests. 
 
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 Outpatient Diagnostic Tests and Therapeutic Services And Supplies.  
 
You have been asked to pay a $10 copayment for laboratory services performed on December 30, 2021. 
Laboratory services fall within the Outpatient Diagnostic Tests and Therapeutic Services And Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive your $10 copayment for laboratory services performed on 
December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $40 copayment for an office visit on February 14, 2022. 
 
You asked the Plan to waive your $40 copayment an office visit on February 14, 2022. You say that you should 
not have to pay your copayment because the Plan required you to have a second opinion. The Plan denied your 
request. The Plan says you must pay a $40 copayment for each in-network specialist visit or telehealth visit for 
Medicare-covered benefits. 
 
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 $40 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
 
 
 
You have been asked to pay a $40 copayment for an office visit on February 14, 2022. An office visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits 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 your $40 copayment for an office visit on February 14, 2022.