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 from July 3, 2021, to August 1, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee not require skilled nursing 
or therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of service criteria 
for 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 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 from July 3, 2021, to August 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on December 2, 
2020. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met.  Specifically, the claim was billed with the laboratory place of service code while the records suggest that the 
member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not 
have to pay for the drug testing services (G0483) provided on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor 2 and Factor 5 gene analysis services. 
 
You asked the Plan to pre-approve Factor 2 and Factor 5 gene analysis services. You say that the genetic 
testing being requested is medically necessary. The Plan denied your request. The Plan says genetic testing for 
the requested genes is not covered except for pregnant patients. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for inherited thrombophilias 
outside the pregnant women is considered investigational.  
 
We looked at the file and Medicare rules. The enrollee in this case is not pregnant. Based on this information, 
we decided that Medicare rules for coverage of Factor 2 and Factor 5 gene analysis services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Factor 2 and Factor 5 gene analysis services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation services. You say that the requested treatment is 
part of a multi-modal approach to the treatment of chronic pain. You say that this treatment will help the 
enrollee return to an acceptable functional status. The Plan denied your request. The Plan says it is not 
medically necessary to have the requested procedure at the sacroiliac joint. 
 
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 radiofrequency ablation services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental and investigational because of the wide 
variation in effectiveness reported in the literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation 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 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 at least 3 hours a day / 5 days a week, or 15 hours over 7 
consecutive days, of therapy services. The enrollee will not 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on August 9, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a home health visit. You say that the facility should get prior authorization and it 
was medically necessary for the physician to see the enrollee. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no approved prior authorization. Also, the 
services provided were not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on August 9, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve the repairs. You say that this is medically necessary. The Plan denied your 
request. The Plan says the cost of the requested repairs appears to exceed the cost of a replacement of the 
wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs that are more expensive than replacing 
the durable medical equipment 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 the repairs. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that supports medical necessity for coverage of the cost of the requested 
repairs to the wheelchair as defined by Medicare criteria as total repairs on the power wheelchair exceed the 
cost of replacement. 
 
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 repairs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair repairs.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract laser surgery (66821) provided on 
July 30, 2021. 
 
You asked the Plan to waive the copayment for the cataract laser surgery. You say that the services should be 
covered as you were told you would only have a $45 specialist copayment. The Plan denied your request. The 
Plan says the cost-sharing applied correctly based on the service provided. 
 
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 $300 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  
You have been asked to pay a $300 copayment for cataract laser surgery. Cataract laser surgery falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 cataract laser surgery (66821) 
provided on July 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing services provided on August 26, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory testing services. You say that you would like this claim to be 
reconsidered and processed for payment. The Plan denied your request. The Plan says these services were 
rendered by an OON provider, nor were they referred by a network provider or rendered in a participating 
facility. The Plan also says that these services were not urgent or emergent, nor were they approved in advance. 
 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 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 laboratory testing services provided on August 
26, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 13, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-
of-network with the Plan and authorization was not obtained. 
 
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 testing provided on January 13, 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 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. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehab facility admission and 
services provided from August 6, 2021, to August 21, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were under the impression 
that you were going to a skilled nursing facility and these services would be provided at no cost to you. The 
Plan denied your request. The Plan says the facility in this case is an inpatient rehabilitation facility. This claim 
was processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 $200 
copayment for each of the first five days of an inpatient hospital stay.  
 You have been asked to pay a 1,000 copayment for the inpatient rehabilitation care which lasted more than five 
days ($200 x 5 = $1,000). This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient rehab facility 
admission and services provided from August 6, 2021, to August 21, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial and subsequent hospital care services (99233 and 99223) 
provided on July 8, 2021, through July 9, 2021. 
 
You asked the Plan to pay for the initial and subsequent hospital care services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that these services 
have already been processed and paid. 
 
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 submitted any evidence that CPT codes 99233 and 
99223 have been previously processed and paid. It is the burden of the Health Plan to substantiate their denial 
with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for the initial and subsequent hospital care services (99233 and 
99223) provided on July 8, 2021, through July 9, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation provided on September 15, 2021. 
 
You asked the Plan to pay for the services provided. You say that the code was entered incorrectly. The Plan 
denied your request. The Plan says the code is not recognized by Medicare for reimbursement purposes. 
 
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, the CPT Code Manual definition of code S0285 is colonoscopy consultation performed prior to a 
screening colonoscopy procedure. We find that CPT code S0285 is not valid for Medicare purposes. Medicare 
uses another code for this service. Based on this information, we decided that Medicare rules for coverage of 
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
consultation provided on September 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy and occupational therapy services 
provided from July 1, 2021, to August 31, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy and occupational therapy services. You say that the services 
rendered were medically necessary and authorization was received prior to admission. You also say that you 
would like this claim to be reprocessed and paid correctly. The Plan denied your request. The Plan says these 
services were rendered by an OON provider. The Plan also says that these services are not urgent or emergent, 
nor were they approved in advance. 
 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 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 physical therapy and occupational therapy 
services provided from July 1, 2021, to August 31, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Joimax endoscopic decompression surgery of the spinal 
cord for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the endoscopic 
decompression surgery in the setting of low back pain has not been demonstrated in the peer-reviewed 
literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Endoscopic 
decompression remains experimental in cases of spine surgery. More research is needed to show safety and 
efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Joimax endoscopic decompression surgery of the spinal cord for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that the enrollee is unable to go home at this point 
and needs the short term rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for this admission. 
 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 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, can as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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) for the enrollee.