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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered 
medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records 
show you are medically stable and you do not need physician supervision 3 times per week (at a minimum) for 
the ongoing management of any active or acute exacerbations of chronic medical conditions. 
 At the current functional level, you do not need intensive therapies, consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. IRF admission is not 
medically necessary based on lack of medical complexity and lack of acute rehab nursing needs and high 
functional level. Medicare coverage criteria are not met. 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 mass spectrometry and tandem mass spectrometry (83789) 
provided on August 3, 2021. 
 You asked the Plan to pay for mass spectrometry and tandem mass spectrometry. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists 
between CPT codes 80307 and G0480. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 mass spectrometry and tandem mass spectrometry. Our 
reviewer says that CPT code 83789 does not meet criteria for billing or reimbursement consideration. Our 
reviewer found the documentation does not support modifier -59 as a distinct procedure, and would be included 
in HCPCS G0480 and CPT 80307, as validity testing is not separately reported for specimens used for drug 
testing. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mass spectrometry and tandem mass spectrometry have not been met. 
Therefore, we decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry 
(83789) provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99205) provided on July 29, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that your office was not in charge of securing an 
authorization for both dates of service and that it was the responsibility of the hospital. The Plan denied your 
request. The Plan says the services were rendered and referred by non-participating providers and the Plan has 
also determined 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 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 specialist office visit (99205) provided on July 
29, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visits provided on November 18, 2021, and 
November 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visits. You say that you would like to appeal the denied 
charges. The Plan denied your request. The Plan says the rendering and referring are both out-of-network 
providers and there was no approved authorization for services. Also, the service rendered was 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 specialist office visits provided on November 18, 
2021, and November 24, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or neck 
(70450) provided on November 8, 2021. 
 You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says an appropriate modifier was not 
billed with this claim. 
 
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 computed tomography (CT) scan of the head or neck (70450) 
provided on November 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from February 8, 
2021, to February 12, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the enrollee hit there 
MOOP and should not be charged a copayment for this service. The Plan denied your request. The Plan says 
the proper copayment was applied because the enrollee did not hit there MOOP prior to the date of service. 
 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 $4,500 
maximum out-of-pocket amount for in-network covered Part A and Part B services. If you reach the maximum 
out-of-pocket (MOOP) amount of $4,500, you will not have to pay any out-of-pocket costs for the rest of the 
year for in-network covered Part A and Part B services. Your contract with the Plan clearly says that you must 
pay a $360 copayment for each Medicare-covered inpatient hospital stay per day for days 1-5. Prior to the date 
of service, the total MOOP paid was $3,060. The total copayment amount charged was $1,440 ($360 
copayment x 4 days). Once the copayment was applied the total MOOP amount paid was $4,500 ($3,060 prior 
MOOP + $1,440 copayment). 
 
You have been asked to pay a $1,440 copayment for an inpatient hospital stay. 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 from February 8, 2021, to February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to reimburse you for the Continuous Positive Airway Pressure (CPAP) device 
provided to you on September 16, 2021. 
 
You asked the Plan to reimburse you for the CPAP device. You say that you would like reconsideration 
because your CPAP device has been recalled and there is no timeframe as to when a new CPAP may be 
supplied. The Plan denied your request. The Plan says that network providers are the doctors and other health 
care professionals, such as durable medical equipment suppliers, that have an agreement with us to accept our 
payment and any plan cost-sharing as 
payment in full. 
 
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, it is not clear that the Plan is doing their due diligence to ensure 
that the member is being provided with necessary services/equipment. Additionally, the Plan has not indicated 
if there is a network provider available to provide the necessary equipment or if they are working with a 
network provider to ensure that you are given loaner or replacement equipment until a resolution is known. 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 reimburse you for 
the Continuous Positive Airway Pressure (CPAP) device provided to you on September 16, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you have a fast-growing skin cancer. The Plan 
denied your request. The Plan says there are in-network providers that can provide the services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
dermatology services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says continued treatments and care that can only be given in a hospital setting 
are not required. 
 
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 you were admitted for a bowel obstruction and required operative intervention.  The 
record indicates that the enrollee is improving. You continue to receive acute care services and these have not 
been denied. The medical record does not indicate that you require services that you are not currently receiving 
but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
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 admission to a long term acute care hospital (LTACH).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hydration infusion services provided on 
October 11, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that this was an integral 
part of obtaining a computed tomography (CT) scan, so it should be considered in relation to the other 3 claims 
filed. The Plan denied your request. The Plan says the copayment amount you are being charged 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 $275 
copayment for in-network infusion services at an outpatient hospital.  
 
 You have been asked to pay the allowed amount of $271.62, which is less than the $275 copayment for 
outpatient hospital services. Outpatient hospital services fall within the Outpatient Surgery and Other Medical 
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 hydration infusion services provided on October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 3, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that services were provided to the enrollee 
because the physician sent you the laboratory specimens and the claim should be paid. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an 
in-network provider or an approved authorization. Also, the service rendered was 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 the laboratory services provided on November 3, 
2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on September 25, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical services came to help you up off the floor after you fell. The Plan denied your request. The 
Plan says this claim processed correctly. The Plan also says that this service is not covered by Medicare or the 
Plan. 
 
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 September 25, 2021. 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 the ambulance response and treatment with no 
transport (A0998) provided on September 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide (HHA) for custodial services. 
 
You asked the Plan to pre-approve the HHA. You say that you need home care services for activities of daily 
living such as bathing and using the restroom. The Plan denied your request. The Plan says home health 
services for help with daily tasks, bathing or household chores are not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the HHA have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
home health aide (HHA) for custodial services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
has no acute symptoms that require 24-hour inpatient care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued inpatient services from March 17, 2022, forward were requested. 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 services. Our physician reviewer found that it was not expected 
that this enrollee would improve in a reasonable period of time beyond the dates in question. He was not going 
through any withdrawal symptoms. He did not have any suicidal or homicidal thoughts, auditory or visual 
hallucinations or abnormal behaviors. He was not a danger to himself or others and did not have any delusions, 
auditory or visual hallucinations. 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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar 
(CPT code 22514). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the request is not medically necessary because the compression fracture is chronic. 
 
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 service. Our physician reviewer 
found there is no imaging study such as magnetic resonance imaging (MRI) that shows that there is an acute 
fracture less than twelve (12) weeks old. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; lumbar (CPT code 22514).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from March 
14, 2022, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the request is not medically necessary because the records 
received show that your condition has improved, and you are no longer meet inpatient detoxification criteria. 
 
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 mental health care. Our 
physician reviewer found you do not meet the criteria for treatment in an acute inpatient mental 
health/detoxification treatment beyond the date in question of March 14, 2022, forward and could have been 
treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or 
visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and 
compliant while not showing any acute threats to safety. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from March 14, 2022, forward.