Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you were not aware of the requirement of 
obtaining a prior authorization, specifically for this member's plan type at the time of rendering services. The 
Plan denied your request. The Plan says the facility is a non-participating provider and the referring provider 
involved in these services is also non-participating. The Plan also says that the Plan did not authorize any 
services for this provider or facility. 
 
 
 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 laboratory services provided on December 20, 
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 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services received on January 7, 2022. 
 
You asked the Plan to pay for the services. You say that you were advised that you could deny transport after 
the test was completed. The Plan denied your request. The Plan says this is not covered, due to non-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 January 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services received on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be provided through an out-of-network 
provider. 
 
You asked the Plan to pre-approve out-of-network hearing aids. You say that you can only drive to familiar 
places and your spouse cannot drive you anywhere. The Plan denied your request. The Plan says routine 
hearing services must be received from a provider in the Plan's routine hearing vendor network. There are 
network providers in your area who are able to provide these services. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received through the specified hearing vendor network.  
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The requested provider is not part of the Plans vendor network. 
Based on this information, we decided that the Plan's rules for coverage of out-of-network hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be provided 
through an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided April 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81479) provided April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit (99203) acupuncture, initial 15 minutes 
(97810) acupuncture, one or more needles, each additional 15 minutes (97811) provided October 13, 2021 to 
October 19, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that in August 2017 you had a nasty fall and 
broke your femur. Despite the time that has elapsed, you continue to have chronic lingering pain and discomfort in your legs and hip and sought the assistance of this provider. The Plan denied your request. The 
Plan says acupuncture for hip pain is not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the contract says that acupuncture is only covered for 
chronic low back pain. The records show that the acupuncture services provided was for hip pain. Therefore, 
we decided that the Plan does not have to pay for outpatient office visit (99203) acupuncture, initial 15 minutes 
(97810) acupuncture, one or more needles, each additional 15 minutes (97811) provided October 13, 2021 to 
October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation (unattended) other than wound care, a 
therapeutic, prophylactic, or diagnostic injection, a therapeutic procedure on 1 or more areas, a vasopneumatic 
device therapy, an unknown drug injection, a thiamine hcl 100 mg injection, a pyridoxine hcl 100 mg injection, 
and a levocarnitine injection provided on July 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for electrical stimulation (unattended) other than wound care, a therapeutic, 
prophylactic, or diagnostic injection, a therapeutic procedure on 1 or more areas, a vasopneumatic device 
therapy, an unknown drug injection, a thiamine hcl 100 mg injection, a pyridoxine hcl 100 mg injection, and a 
levocarnitine injection. You say that you are appealing with supporting records. The Plan denied your request. 
The Plan says the services are not authorized because the rendering provider is a non-network provider who 
does not work with the members health plan, and the member self-directed for care. The Plan also says that the 
member's primary care provider did not refer for services, and no medical necessity for an out-of-network 
provider, such as an urgent or emergency situation, has been documented. The Plan also says that there is no 
network deficiency for these services and alternate network providers were found. 
 
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 electrical stimulation (unattended) other than 
wound care, a therapeutic, prophylactic, or diagnostic injection, a therapeutic procedure on 1 or more areas, a 
vasopneumatic device therapy, an unknown drug injection, a thiamine hcl 100 mg injection, a pyridoxine hcl 
100 mg injection, and a levocarnitine injection provided on July 12, 2021, by an out-of-network (OON) 
provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97110) provided on October 12, 2021. 
 
You asked the Plan to pay for the therapy services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the 
services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist.  
We find that CPT code 97110 is not supported in the record. Specifically, this claim was billed by a Nurse 
Practitioner while the record indicates that the therapy service at issue was rendered by a PTA. The services of 
a PTA cannot be billed as incident to a physician/NPP as they do not meet the qualifications of a therapist.  
Based on this information, we decided that Medicare rules for coverage of the therapy services have not been 
met. Therefore, we decided that the Plan does not have to pay for the therapy services (97110) provided on 
October 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
September 30, 2021, to October 5, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not aware that 
you would have a $250 copayment per day since the treatment was for COVID-19. You also say that you 
cannot afford the charges. 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 $250 
copayment per day for days 1-7 for an inpatient hospital stay. The contract also says that there is a $0 
copayment for days 8-90. The record shows that the cost share waiver for COVID-19 treatment expired on May 31, 2021. You have been 
asked to pay a total of $1,250, which is a $250 copayment per day for a five-day inpatient hospital stay from 
September 30, 2021, to October 5, 2021 ($250 copayment x 5 days = $1,250). There is no charge for the day of 
discharge. An inpatient hospital stay 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 an inpatient hospital stay provided from September 30, 2021, to 
October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 10, 
2021, to December 11, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services should be covered. The 
Plan denied your request. The Plan says the inpatient stay was not medically necessary. 
 
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 acute inpatient hospital care. 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 provided record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that your necessary hospital care (including earlier ED and/or observation care) 
would span two 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 10, 2021, to December 
11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the required services can be safely received in a different setting, for example, 
perhaps home with home health, or in long-term care with intermittent services. 
 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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided, there is no documentation that the patient requires skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care. There is no 
documentation that daily skilled services are required. The patient is walking household distances with a 
wheeled walker with supervision and is supervision for transfers. The provided records do not document a 
significant decline in the patients functional status to necessitate daily inpatient skilled therapy services. There 
is no documentation that the patient requires the services on an inpatient basis, only in a skilled nursing facility 
setting. The records do not document that services in the home with home health care or in a long-term care 
facility on a part time basis are not 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the test for detection of respiratory disease-causing 
organisms from back of nose and throat (nasopharynx) specimen (0202U) provided on November 9, 2021. 
 You asked the Plan to pay for the test for detection of respiratory disease-causing organisms. You say that you 
would like this claim to be reviewed for medical necessity. The Plan denied your request. The Plan says panels 
with greater than 5 respiratory pathogens performed in the Part B outpatient setting are considered not 
medically reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that panels with greater than 5 respiratory pathogens 
performed in the Part B outpatient setting is not medically reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the test for detection of respiratory disease-
causing organisms. Our reviewer says that this test does not meet the criteria for coverage. Our physician 
reviewer found the documented nasopharynx testing was for more than 5 pathogens which disqualifies it from 
coverage as it was not equal to or less than 5 pathogens. 
 
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 test for detection of respiratory disease-causing organisms have not been 
met. Therefore, we decided that the Plan does not have to pay for the test for detection of respiratory disease-
causing organisms from back of nose and throat (nasopharynx) specimen (0202U) provided on November 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a psychiatry specialist office visit provided 
on November 19, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you met your maximum 
out-of-pocket (MOOP). 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 a specialist office visit.  
 
The record shows you did not meet your MOOP at the time this claim was processed. You have been asked to 
pay a $35 copayment for a specialist office visit. A specialist office visit falls within the Physician/Practitioner 
Services, Including Doctors 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 the copayment 
for a psychiatry specialist office visit provided on November 19, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the pelvis for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not show results of prior picture studies, such as x-ray or ultrasound. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the current practice in 
urology for patients with possible prostate cancer is to attempt the location for biopsy using MRI rather than 
proceeding with random biopsies under ultrasound. The urologist's notes clearly indicate this is the reason for 
the MRI. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the pelvis for the enrollee.  
 
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 continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found your functional level does not 
require skilled therapy services with the specialized skill, knowledge, and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a 
practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 
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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.