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

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation provided August 26, 
2019, to September 10, 2019. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the cost share has been 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 $195 
copayment per day, per Medicare-covered stay, which includes the day of admission and day of discharge. 
After the eighth day, the Plan pays 100% of covered expenses.  
 
You have been asked to pay $1560 for inpatient rehabilitation. Inpatient rehabilitation falls within the Inpatient 
Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient rehabilitation 
provided August 26, 2019, to September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
acute level of care and a skilled nursing facility (SNF) discharge is not adequate for the enrollee's needs. The 
Plan denied your request. The Plan says that the records do not show that the enrollee needs an intensive team 
approach for their care. The enrollee does not need to be seen by a rehabilitation doctor 3 times a week or 
needs an inpatient rehabilitation stay to get better. Hospital records show that the enrollee's medical conditions 
have improved, and they can safely receive their care in a less intensive setting like a SNF. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollee does require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program at least 3 hours a day and 5 days a week, 
or 15 hours over 7 consecutive days. As of September 19, 2022, the enrollee requires minimum assistance with 
upper body dressing and is dependent with lower body dressing as well as toileting. The enrollee is also noted 
to have moderate oropharyngeal dysphagia. The enrollee requires moderate assistance with ambulation with a 
walker. The enrollee has had a functional decline from their baseline level of function and would benefit from 
the intensity of therapies provided on acute inpatient rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
  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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, methadone provided on 
January 4, 2021, to July 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for medication assisted treatment, methadone. You say that you are appealing the 
claim payment denial. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advanced. 
  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 medication assisted treatment, methadone 
provided on January 4, 2021, to July 12, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires a multi-disciplinary 
approved to manage their medical and physical issues. The Plan denied your request. The Plan says the records 
do not show that the enrollee is expected to improve with LTACH care. The enrollee's continued care needs 
include ventilator care and skilled nursing care. The enrollee can safely receive this care in another setting like 
a skilled nursing facility or at home with home health services or outpatient setting if appropriate. 
 
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 enrollee appears to still be somewhat unstable but improving and should only 
require short-term additional acute care services that can safely be administered at the current facility until 
more stable and appropriate for transfer. The enrollee does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary at 
this time as the enrollee is not yet stable for transfer. 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 the LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 30 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 30 routine transportation trips (A0120). You say that you need 
additional transportation for medical appointments. The Plan denied your request. The Plan says you have used 
56 one-way trips. Your benefit only allows for 60 one-way trips. An additional 30 trips would exceed your 
benefit limit. 
 
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 60 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 30 routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the $100 allowance per quarter for Over-the-Counter 
(OTC) drugs to be reinstated for the first and second quarters of 2022. 
 
You asked the Plan to pre-approve the $100 allowance per quarter for the first and second quarters. You say 
that you feel you should be given the previous quarterly allowances to use for orders. The Plan denied your 
request. The Plan says any unused quarterly benefit is forfeited at the end of each quarter. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. The Plan offers 
a supplemental benefit for OTC items, and the 2022 Evidence of Coverage clearly states that unused quarterly 
allowances cannot be carried over to another quarter. Therefore, we decided that the Plan does not have to pre-
approve the $100 allowance per quarter for Over-the-Counter (OTC) drugs to be reinstated for the first and 
second quarters of 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 11, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81328, 81355, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 11, 2022, billed with codes 81227, 81230, 81231, 81232, 81328, 81355, 0031U, 0032U, and 0033U.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice services provided to the enrollee on December 2, 
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 no payment can be issued. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospice services provided to the enrollee on December 2, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve a panniculectomy. You say that the requested panniculectomy is medically 
necessary. The Plan denied your request. The Plan says the requested panniculectomy is not medically 
necessary. 
 
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 pre-approve a panniculectomy. Our reviewer says 
that the requested panniculectomy is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has excessive and redundant skin and subcutaneous tissue in the setting of a prior 
bariatric surgery procedure. The record indicates that the enrollee will be undergoing repair of ventral and 
umbilical hernia. The record does not indicate the presence of intertrigo refractory to conservative medical 
treatment or functional limitation. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. The requested service is not 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 a panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 28, 2022. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the testing was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization long-term acute care hospital admission. The Plan denied your request. The Plan says you are 
receiving appropriate inpatient acute care and are currently unstable for transfer to an LTACH. 
 
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 at the time of the request, you have not completed the acute stay and are medically 
unstable for transfer due to a planned procedure that has not occurred. Your pulmonary status is also unstable 
due to abdominal findings on the most recent chest x-ray. There is no documentation provided indicating 
medical necessity for admission to a LTACH. You are receiving appropriate care at the present acute care 
hospital. You do not require services at the LTACH that are not available at the acute care hospital where they 
are currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on February 11, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 99 for other 
place of service; however, the services should be billed with POS code 02 (telehealth other than patient's home) 
or 10 (telehealth in patient's home). Therefore, we decided that the Plan does not have to pay for the telehealth 
services rendered on February 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service April 22, 2022.
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 complexity of your nursing medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven 
consecutive days. Therefore, the acute inpatient rehabilitation admission is not 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 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 Invitae Aortopathy Comprehensive Panel (81411, 81410) 
provided May 4, 2022. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing should be covered. The Plan 
denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. The rules say that molecular diagnostic laboratory tests are subject to the 
MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the Invitae Aortopathy Comprehensive Panel (81411, 81410) provided May 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an exploratory arthrotomy of the elbow (24000) and a 
treatment of ulnar fracture (24670) billed for date of service February 6, 2022. 
 You asked the Plan to pay for an exploratory arthrotomy of the elbow and a treatment of ulnar fracture. You 
say that the services at issue are separately reimbursable and not inclusive. The Plan denied your request. The 
Plan says the services at issue are included in other billed codes. 
 
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 24000 is a column II code to column I codes 11012 and 24685 and 
that code 24670 is a column II code to column I code 24685. However, codes 24000 and 24670 were billed 
with a modifier.  
 
We asked our coder 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 exploratory arthrotomy of the elbow and a treatment of ulnar 
fracture. Our reviewer says that the codes at issue do not meet criteria for payment. Our reviewer found that the 
available documentation does not support the use of procedure code 24000 as it was not distinct and separate 
from the procedure codes 11012 and 24685, also performed on the left side. Neither does the documentation 
support the use of procedure code 24670 as it was not distinct from procedure code 24685 that was also 
performed on the left side. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of exploratory arthrotomy of the elbow and a treatment of ulnar fracture have not 
been met. Therefore, we decided that the Plan does not have to pay for an exploratory arthrotomy of the elbow 
(24000) and a treatment of ulnar fracture (24670) billed for date of service February 6, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health speech-language pathology services provided from 
February 1, 2022, to February 15, 2022. 
 
You asked the Plan to pay for home health speech-language pathology services. The Plan denied your request. 
The Plan says that the claim was billed incorrectly and accurate billing of non-par home health claims is 
necessary for accurate reimbursement. A corrected claim can be submitted with accurate information for claim 
reconsideration. 
 
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, the Plan has not given us a rule that proves these codes cannot be 
paid as billed. Therefore, we decided that the Plan has to pay for home health speech-language pathology 
services provided from February 1, 2022, to February 15, 2022.  
 
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.