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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on March 5, 2020, to March 15, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance 
Prospective Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the case file does not contain 
documentation by the physician that supports a diagnosis of malnutrition or evidence of a risk for malnutrition. 
 
We looked at this coder'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 pay for skilled nursing facility (SNF) services provided to the enrollee on March 5, 2020, to March 15, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network primary care provider 
(PCP). 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested PCP is not a plan provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network primary care provider (PCP).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided to the enrollee on January 26, 
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 there is no no established relationship with the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of telehealth services provided to the 
enrollee on January 26, 2021. have been met. The provider did not send any relevant evidence to prove that 
these services were actually rendered. There is no evidence of an established relationship between the provider 
and the enrollee.. Therefore, we decided that the Plan does not have to pay for telehealth services provided to 
the enrollee on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CologuardTM test provided on January 13, 2021. 
 
You asked the Plan to pay for the Cologuard test. You say that you feel that it is not fair for you to be charged 
this excessive amount when you were not told that it would not be covered. The Plan denied your request. The 
Plan says you had this same test less than 48 months ago. As such, this cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard testing is covered for certain patients 
once every three years.  
 
We looked at the file and the Medicare rules. The documentation shows that you were provided with this test 
on August 28, 2019, less than three years before this current test. Therefore, we decided that the Plan does not 
have to pay for the CologuardTM test provided on January 13, 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 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  You were admitted for subarachnoid and subdural hemorrhage after a fall and were transferred to skilled 
nursing. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0242U) provided May 25, 2021. 
 
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 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 (0242U) provided May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve the mechanism. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 mechanism. Our reviewer says that 
the requested mechanism is not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not indicate that you are incapable of standing from a regular armchair or any chair in the 
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 the mechanism have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that your condition has improved, and you 
are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you will improve in a reasonable period of time as you do not have suicidal or homicidal ideation 
noted and no auditory or visual hallucinations. You do not show any abnormal behaviors or any symptoms 
which would require acute treatment. It does not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care as you do not have 
dangerousness to self or others and were compliant with your treatment with encouragement. Our physician 
reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided May 28, 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 billed services. 
 
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 May 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided 
from October 6, 2021, to October 20, 2021. 
 
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you feel that 
the copayment is too high. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct 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 $40 
copayment for outpatient rehabilitation services.  
 
You received outpatient rehabilitation services from October 6, 2021, to October 20, 2021, for a total of 3 
visits. Therefore, you are responsible to pay a $40 copayment per each visit.  The total amount you owe is: $40 (copayment) x 3 (outpatient rehabilitation service) = $120.  
 
You have been asked to pay the total copayment amount of $120 for outpatient rehabilitation services. 
Outpatient rehabilitation 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 outpatient rehabilitation services provided from October 6, 2021, to 
October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound debridement services (11042) provided on 
October 21, 2021 to October 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services. You say that please review and process payment for the 
medically necessary services rendered. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider. The plan says if an enrollee requires medical care that 
Medicare requires the plan to cover and there are no in-network providers who can provide the care then the 
enrollee can receive the care from an out-of-network provider. 
 
 
 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 wound debridement services (11042) provided 
on October 21, 2021 to October 28, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay from November 27, 2020, to December 7, 2020. 
 
You asked the Plan to pay for the services. You say that this claim was billed correctly and the diagnoses are 
supported in the record. The Plan denied your request. The Plan says that the record shows pneumonia, 
unspecified organism (J18.9) is the principal diagnosis in this case, and therefore DRG 193 is more appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 services. Our reviewer says that the services at issue in this case were 
supported by the medical records. Our physician reviewer found sepsis should be defined as life-threatening 
organ dysfunction caused by a dysregulated host response to infection. The documentation supports that the 
enrollee in this case had life-threatening organ dysfunction caused by a dysregulated host response to infection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient stay from November 27, 2020, to December 7, 2020. 
  
 
 
 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction (97012) and electrical stimulation 
(G0283) provided October20, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that please review and reprocess for payment 
on 97012 and G0283. The Plan denied your request. The Plan says these services are not covered when 
rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for mechanical traction (97012) and electrical stimulation (G0283) provided 
October20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services coded as 97810 and 97811 on 
October 13, 2021. 
 You asked the Plan to pay for the acupuncture services. You say that this claim was denied pending medical 
notes. The requested medical notes are attached. The Plan denied your request. The Plan says the services were 
rendered by a non-covered provider type. 
 
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 services were rendered by a licensed 
acupuncturist, not a physician. The health Plan contract says that the services must be provided by a legally 
qualified physician practicing within the scope of their license. Therefore, we decided that the Plan does not 
have to pay for the acupuncture services coded as 97810 and 97811 on October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on November 4, 
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 November 4, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ER visit and an ECG provided on September 17, 2020 
 
You asked the Plan to pay for the ER visit and an ECG. You say that the services should be paid for as the 
claim processed incorrectly. The Plan denied your request. The Plan says they are not liable for payment, and it 
falls under the provider to reimburse you. 
 
The Plan must follow Medicare rules. Medicare rules say that for services of a non-contracting, original 
Medicare, participating provider; there is no balance billing paid by either the plan or the enrollee. You can 
find this information in the Centers for Medicare and Medicaid Services Internet Only Manual, Medicare 
Managed Care Manual, Chapter 4, Section 170. 
 
 
 
 
 
 
 
 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ER visit have not been met. Specifically, neither you nor the Plan are responsible for payment. 
Contact the provider regarding reimbursement. Therefore, we decided that the Plan does not have to pay for the 
ER visit provided on September 17, 2020.