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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for approval of IRF. 
 
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 was admitted to an acute hospital with failure to thrive, debility and 
a compression fracture. The enrollee is stable medically and comorbid conditions are stable. No acute 
rehabilitation nursing needs have been identified or documented. While then enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. The 
enrollee's needs can be safely provided in a lower intensity and alternate setting such as in a skilled nursing 
facility. 
 
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 genetic testing services (81479) provided on August 12, 
2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
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 the genetic testing services (81479) provided on August 12, 2021, have been met. In this case, no medical records were submitted to support the 
necessity and reasonablenes of the requested testing. Therefore, we decided that the Plan does not have to pay 
for the genetic testing services (81479) provided on August 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued SNF services. You say that the patient will be unsafe at home. 
You also say that the family feels she will be unsafe navigating independently. The Plan denied your request. 
The Plan says based on Medicare guidelines and the information they have about the enrollee's condition; she 
does not meet all the requirements. 
 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 services. Our reviewer 
says that this does not meet criteria. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation therapy provided on January 5, 2022, to 
February 22, 2022. 
 
You asked the Plan to pay for electrical stimulation therapy. You say that this service should be covered. The 
Plan denied your request. The Plan says the cost share applied is correct. 
 
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 electrical stimulation therapy provided on January 5, 2022, to February 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a shoulder orthosis (sling) provided on 
September 8, 2021. 
 
You asked the Plan to waive the coinsurance for the shoulder sling. You say that the cost should have been 
included in your urgent care visit copayment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for orthotic devices and supplies.  
 
You have been asked to pay $18.88, which is 20% of the allowed amount for the shoulder sling ($94.40 
allowed amount x 20% coinsurance = $18.88). The shoulder sling falls within the Prosthetic Devices and 
Related Supplies benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a shoulder orthosis 
(sling) provided on September 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 13, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the nursing home 
should have been able to handle the problem. The Plan denied your request. The Plan says the enrollee has 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment for each one-way ambulance trip.  
 The enrollee has been asked to pay a $225 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance Services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for ambulance transportation provided on November 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services received on September 21, 2020. 
 
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 failed to submit a plan of care for the date of service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
There are multiple issues with the way that the denied home health services were reported. A review of the 
records shows no plan of care for the services billed. Additionally, there were no orders for this visit, or a 
submitted OASIS. 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 home health services received on 
September 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
December 2, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the nursing home 
should have been able to handle the problem. The Plan denied your request. The Plan says the enrollee has 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment for each one-way ambulance trip.  
 The enrollee has been asked to pay $113.45, which is less than the $225 copayment for the ambulance 
transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for ambulance transportation provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician services provided on January 12, 
2022. 
 
You asked the Plan to waive the copayment for physician services. You say that this charge should be covered. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $15 
copayment for services obtained from a primary care provider or under certain circumstances, treatment by a 
nurse practitioner or physicians assistant or other non-physician health care professionals in a primary care 
providers office. 
 
 You have been asked to pay $15 copayment for physician services. Physician services fall 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 physician services provided on January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on February 11, 2022. 
  You asked the Plan to pay for the CT scan (70450). You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this 
code edit. 
 
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 the CT scan (70450) provided on February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the requested ventilator does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease and bronchiectasis. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. AVAPS mode has been ordered. The enrollee could be treated with a BiPAP machine 
with AVAPS capability. The plan has indicated such a device is available for coverage upon request. 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 
14, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you shouldn't have a 
copayment for diagnostic testing The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $25 
copayment for each specialist office visit.  
 
You have been asked to pay $25 copayment for specialist office visit. Specialist office visits fall 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 specialist office visit provided on March 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography (ERCP) 
coded 43262 provided on January 10, 2022. 
 You asked the Plan to pay for ERCP. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the services 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 code 43262 
is a column II code to column I code 43274. 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 the endoscopic retrograde cholangiopancreatography (ERCP) 
coded 43262 provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit, electrocardiogram 
(ECG), and myocardial perfusion (SPECT) imaging provided on January 11, 2022. 
 
You asked the Plan to waive the copayments for the office visit, ECG, and SPECT imaging. You say that the 
services should be covered due to your COVID-19 diagnosis. 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 $45 
copayment for each specialist visit. 
 
Your contract with the Plan also clearly says that you must pay a $5 copayment for diagnostic lab services, procedures and tests and a $110 copayment for each advanced imaging service. 
 
You have been asked to pay a $45 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay a $5 copayment for the ECG and a $110 copayment for the SPECT imaging. The ECG and SPECT 
imaging fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
The total for the services is $160. 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 a specialist office 
visit, electrocardiogram (ECG), and myocardial perfusion (SPECT) imaging provided on January 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on 
November 5, 2021, and November 8, 2021. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you reached your out-of-
pocket maximum so these visits should be covered. The Plan denied your request. The Plan says the 
copayments applied are correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $20 
copayment for each Medicare covered physical therapy and speech language therapy visit. 
 
 
 
 You have been asked to pay $40 ($20 x2 visits) copayment for physical therapy visits. Physical therapy visits 
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 
copayment for physical therapy visits provided on November 5, 2021, and November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on September 22, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that please review the additional information and grant 
your retro-authorization request. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 office visit (99213) provided on 
September 22, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says based on Medicare guidelines and the information they have about 
your condition; you do not meet all the requirements. 
 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 services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found you do not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BDX-XL2 assay (0080U) provided on December 31, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of the original 
determination to cover the BDX-XL2 test as medically necessary and reimbursement at the rate equal to the 
rate reimbursed for fee for service Medicare beneficiaries of $3,520.00 The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 BDX-XL2 assay (0080U) provided on 
December 31, 2021 by an out-of-network (OON) provider.