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

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on
August 9, 2021.
You asked the Plan to pay for these services. 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 must 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 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 out of network medical services provided to the
enrollee on August 9, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on July 26, 2021. 
 
You asked the Plan to pay for the testing services. You say that there is a misinterpretation of guidelines. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We looked at the file and the rules. The claim lists a place of service as an independent laboratory. If an 
independent lab bills for services, the place where the sample was taken is reported as the POS. The records do 
not show that the same was taken at an independent laboratory.  Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the Guardant360 testing provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided from August 11, 
2021, to October 12, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan because 
you did not know the provider was out of network and you did not know you needed prior authorization. The 
Plan denied your request. The Plan says the Plan contract is clear that out of network services require prior 
authorization. The Plan states that there are no phone records of either yourself or the provider calling the Plan 
to confirm your network benefits.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided from 
August 11, 2021, to October 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have 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 the requested admission to a SNF does not meet 
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 daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or skilled therapy needs. You are ambulating 100 feet and tending to ADLs with minimal supervision.  
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, custodial and intermittent, can, as a practical matter, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional home health skilled nursing visits 
 
You asked the Plan to pre-approve the additional visits. You say that the enrollee is unable to perform wound 
care independently. The Plan denied your request. The Plan says any training or education the enrollee should 
have occurred with the visits they already had. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found the 
enrollee is receiving wound care following drainage of a breast abscess.  Daily wound care was ordered, but 
only thrice weekly visits were requested. The enrollee has been attending medical appointments, calling into 
question her homebound status. There is no evidence that the enrollee is unable to tend to the wound 
herself.  There is no evidence that a caregiver is unable, unwilling or unavailable to tend to the enrollees 
wound. As such, the documentation does not support that the requested home health skilled nursing services 
are medically necessary or reasonable. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 18 additional home health skilled nursing visits
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81295, 81298) provided December 17, 2020. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the codes billed are not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
81295 and 81298 share a bundled relationship with code 81432. 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 lab services (81295, 81298) provided 
December 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit with breast ultrasound you 
had on October 29, 2021. 
 
You asked the Plan to waive the copayments for the office visit and ultrasound. You say that you went to the 
doctor for your routine mammogram but that due to COVID-19, you could not stay to see if the results were 
conclusive.  They were not conclusive, so you had to return on another date.  You do not think you should have 
to pay this copayment. The Plan denied your request. The Plan says you were charged these copayments 
correctly.  The Plan says that when you returned to the office on October 29, 2021, you did have another 
mammogram.  You were not charged a copayment for the repeat mammogram.  However, you also had an 
office visit with the radiology specialist and a breast ultrasound.  The Plan says that copayments appropriately 
applied to these services. 
 
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 $55 
copayment for ultrasounds and a $50 copayment for visits with a specialist.   
You have been asked to pay a $50 copayment for the office visit and a $55 copayment for the ultrasound. 
These copayments apply regardless of the reason for the 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 
copayments for the office visit with breast ultrasound you had on October 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life 
support, emergency transport, level 1(A0427) and ground mileage (A0425) provided October 3, 2021. 
 
You asked the Plan to waive the copayment for the emergency ambulance service. You say that you would like 
this service covered. The Plan denied your request. The Plan says the copayment was applied 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 $440 
copayment for each Medicare-covered one-way trip by ground ambulance.  
 
You have been asked to pay a $440 copayment for the emergency ambulance service. The emergency 
ambulance service falls within the Ambulance 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 the ambulance service, advanced life support, emergency transport, level 1(A0427) and 
ground mileage (A0425) provided October 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services received on October 25, 2021. 
 
You asked the Plan to pay for the services. You say that the charges should be reviewed. The Plan denied your 
request. The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear. 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 services you asked the Plan to pay for are considered routine vision services or eyewear. There is a $50 
copayment applied to the office visit, and the full price for the refraction must be paid, as this type of service is not covered. Therefore, we decided that the Plan does not have to pay for vision services received on October 
25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection (62322) provided on June 16, 2021. 
 
You asked the Plan to pay for an injection. You say that this is supported in the records. The Plan denied your 
request. The Plan says this cannot be paid without a modifier. 
 
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 62322 is a column II code to column I code 00790. 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 an injection (62322) provided on June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on October 16, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 radiology services provided to the enrollee on October 16, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollees medical conditions are stable on outpatient medications with no issues 
that require a physicians evaluation three or more times per week. The enrollee does not require the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. Care in the home with home 
health or at the skilled nursing facility level appears to be appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay in full for a wig (A9282) provided on May 24, 2021. 
 
You asked the Plan to pay in full for a wig. You say that you have only purchased one wig and deliberately 
purchased a wig that cost less than the Plan's annual allowance. The Plan denied your request. The Plan says 
that the annual benefit for the item at issue has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, you state that you were erroneously billed twice for a single wig. 
This error made it appear that you have exhausted your annual benefit for wigs. The Plan has not provided a 
response to your statement. Their decision to deny your request is not supported and we must find in your 
favor. Therefore, we decided that the Plan has to pay in full for a wig (A9282) provided on May 24, 2021.  
 
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. 
 
Your complaints about being double-billed by your supplier and faabout receiving erroneous or incomplete 
information about your benefits from representatives of the Plan are not valid appeals for medical coverage. 
These parts of your complaint are grievances that must be answered by the Plan. Medicare does not permit us 
to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services provided on May 24, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient therapy services. You say that the services should be covered. The 
Plan denied your request. The Plan says the provider did not verify the enrollee's eligibility prior to rendering 
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 the outpatient therapy services provided on May 
24, 2021 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 domiciliary or rest home visit (99336)  provided on August 
24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it is the nursing facility's 
responsibility to get authorization for their patients. You also say that it was medically necessary for the patient 
to receive the treatment by this provider, and you did not know that the facility failed to get preauthorization 
for this patient. The Plan denied your request. The Plan says prior authorization is required from the Plan for 
this disputed service to be covered. The Plan also says that an authorization was not obtained prior to the 
services being rendered and the provider is not participating with the member's Plan. 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 domiciliary or rest home visit (99336)  provided 
on August 24, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that you have many serious health issues and would 
like a trained professional to come to your home and check your vitals and make sure you are doing alright. 
The Plan denied your request. The Plan says these services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found there are no 
documented skilled nursing needs, i.e. IVs, complex wound care, new ostomy, etc. As such, the requested 
ongoing home health skilled nursing services are not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services.