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 for the enrollee. 
 
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 the member's nursing, medical management and rehabilitation needs do 
not require an interdisciplinary team approach to delivery of rehabilitation care. 
 
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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for acute on chronic 
kidney failure, sepsis, urinary tract infection, and dehydration. The enrollees medical problems are stable. 
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has 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 this patient will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 provided on June 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for physical therapy (PT) 
services provided on August 19, 2021. 
 
You asked the Plan to waive the deductible and coinsurance for the PT services. You say that you had already 
met your deductible. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible and the correct coinsurance was also applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $290 deductible which applies to certain items and services.  
 Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each physical therapy 
visit. 
 
The item or service you asked the Plan to waive the deductible and coinsurance for falls within the Outpatient 
Rehabilitation Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $290 deductible which applies to certain items and services. The file shows that the 
remaining $64.81 was applied to meet your deductible, and you have a 20% coinsurance on the remaining 
$5.19, which is $1.04. Your total for the visit is $65.85. This cost sharing is a contractual obligation that had 
not been met at the time the PT services were received on August 19, 2021. Therefore, we decided that the Plan 
does not have to waive the deductible and coinsurance for physical therapy (PT) services provided on August 
19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress. 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. 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 follows Medicare rules. Medicare rules say that a group 2 support surface is covered if the beneficiary 
meets specific criteria. 
 
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 powered pressure-reducing air 
mattress. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not support that he has multiple stage 2 pressure ulcers located on the trunk or pelvis and 
has failed to improve in the previous month with conservative treatment with a comprehensive ulcer treatment 
program or a myocutaneous flap or skin graft. The requested pressure reducing support surface is not medically 
necessary. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the rendering provider made the appointment and 
you believed they received authorization from the Plan. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and the enrollee's primary care physician sent a referral in for 
the out-of-network provider, but it was denied. Also, there was already an approved referral to see an in-
network provider prior to the date of service. 
 
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 an office visit provided on December 6, 2021, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable contact lenses (S0500) provided August 31, 
2021. 
 You asked the Plan to pay for the contacts. You say that you feel the contacts should be covered under your 
2020 benefits because your eye exam was in 2020. The Plan denied your request. The Plan says the contacts 
are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage.  
 
We looked at the file and the Plan's rules. Though the Plan offer routine vision benefits in excess of Medicare 
coverage, the disposable contact lenses are not among those covered services.  Therefore, we decided that the 
Plan does not have to pay for the disposable contact lenses (S0500) provided August 31, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
December 10, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you went to the emergency room, and 
they did a cardiac catheter procedure. 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 $50 
copayment for an emergency room visit.  
 
 
 The record shows the heart catherization procedure was approved and is considered part of your ER visit 
which, is what the cost share is applied too. You have been asked to pay a $50 copayment for an ER visit. An 
ER visit falls within the Emergency 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 emergency room (ER) visit provided on December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
supplies provided on November 4, 2021. 
 
You asked the Plan to waive the coinsurance for the DME supplies. You say that the provider overcharged and 
would like to file an appeal. The Plan denied your request. The Plan says the claim was processed at the 
Medicare allowed amount, so the proper 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 In-network Medicare-covered durable medical equipment. The total allowed amount was 
$2,931.45 with a coinsurance of $586.29 ($2,931.45 total amount allowed x 20% coinsurance). 
 
  You have been asked to pay a $586.29 coinsurance for the DME supplies. The DME supplies falls within the 
Durable medical equipment (DME) 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 durable medical equipment (DME) supplies provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health visit provided on November 11, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health visit. You say that it was medically necessary to treat the enrollee 
and an authorization could not be completed in a timely manner. The Plan denied your request. The Plan says 
the rendering provider is an out-of-network provider and there was no approved authorization, and it was 
determined that the services rendered were not urgent or emergent. Also, the services rendered could have been 
provided by an in-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 home health visit provided on November 11, 2021 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychotherapy provided on October 5, 2021 to November 
30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Psychotherapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required and it was determined 
these services 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 Psychotherapy provided on October 5, 2021 to 
November 30, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan provided on October 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the duplex scan. You say that you would like the claim reprocessed for payment. 
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 duplex scan provided on October 22, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you do not require full time access to a doctor or any specialized 
equipment. 
 
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 hypokalemia and surgical 
decompression of a mixed tumor of the spinal cord. 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray rendered on September 20, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
knee x-ray rendered on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing coded as 87799, 87798 and 
87482 provided December 27, 2021 by an out of network provider. 
 You asked the Plan to pay for the urine PCR panel testing. You say that please review and process this claim 
following the CMS guidance. The Plan denied your request. The Plan says PCR testing is considered unproven 
and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. PCR testing is considered unproven. The standard of care for the 
evaluation for urinary complaints is urinalysis with urine culture and sensitivity. Additionally, there is no 
documentation in the records of any urinary symptoms or complaints. Based on this information, we decided 
that Medicare rules for coverage of the urine PCR panel testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the Urine PCR panel testing coded as 87799, 87798 and 87482 provided 
December 27, 2021 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wrist hand finger orthosis (L3808) 
provided on December 29, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the item 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 20% 
coinsurance for each Medicare-covered durable medical equipment and related supplies.   
 
You have been asked to pay $59.06 (Plan allowable amount of $295.32 x 20% coinsurance) for the Medicare-
covered durable medical equipment provided.  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 the wrist hand finger orthosis (L3808) provided on 
December 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services (97110, 97112, 97116, 97530, 
97140, 97542) provided from January 18, 2021, to January 22, 2021. You asked the Plan to pay for the physical therapy services. You say that these services were billed correctly, 
as this provider is considered a separate entity from the assisted living facility. The Plan denied your request. 
The Plan says these services were billed with Place of Service (POS) code 11, which indicates that they were 
provided in an office setting; however, the documentation supports that these services were provided in an 
assisted living facility. Therefore, these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the therapy services are not supported in the record as billed. Specifically, the medical record 
indicates that these services were performed at an assisted living facility. Based on this information, we 
decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pay for the physical therapy services (97110, 97112, 97116, 97530, 
97140, 97542) provided from January 18, 2021, to January 22, 2021.