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

 
We decided that the Plan does not have to pre-approve 44 additional round trip non-emergency transportation; 
taxi (A0100). 
 
You asked the Plan to pre-approve the additional transportation. You say that the enrollee is scheduled for 
chemotherapy and radiation treatments. The enrollee has no other means of transportation. The Plan denied 
your request. The Plan says the enrollee has exhausted the benefits for non-emergency transportation. Extra 
one-way transportation trips cannot be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 44 additional round trip non-emergency transportation; taxi 
(A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee from 
February 7, 2022, to February 10, 2022. 
 
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 item obtained by the enrollee was rendered by a provider who is not under contract with the 
health plan and is not certified for Medicare. 
 
The plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no 
exception that would require the plan to pay for these items/services. 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 durable medical equipment provided to the enrollee from February 7, 2022, to February 10, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve above the knee and lower extremity prosthetics (L5321, 
L5650, L5631, L5624, L5649, L5671, L5651, L5812, L5673, L5920, L5845, L5850, L5950, L5970, L5925, 
L8430, L8480, L8460) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee is in desperate need of a right above 
knee prosthesis. You also say the enrollee is a fall risk and desires to regain mobility, after her recent 
amputation. The requested provider is the only company willing to travel to the enrollee's home since she is 
unable to drive to make clinical visits. The Plan denied your request. The Plan says there are in-network 
therapy providers who are available to provide the requested prosthetic services within a reasonable distance 
from the enrollee's location. The Plan also says they are unable to approve this out of network exception. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
above the knee and lower extremity prosthetics (L5321, L5650, L5631, L5624, L5649, L5671, L5651, L5812, 
L5673, L5920, L5845, L5850, L5950, L5970, L5925, L8430, L8480, L8460) 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee and their 
needs cannot be safely met by home health or skilled nursing as demonstrated by their increased safety risk and 
current failure with home health. The Plan denied your request. The Plan says this is not medically necessary, 
and a lower level of care might be appropriate. 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 7, 2021. 
 
You asked the Plan to pay for procedure code 84153. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 84153 is bundled into payment for code 84480. 
 
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 84153 
is a column II code to column I code 84480. 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.  
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 these 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 the laboratory services rendered on December 7, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the 
incorrect DOS was reported on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. In this case, the medical records document that the specimen was 
collected on March 25, 2022. The available documentation does not support an exception to the Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service 
April 22, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility (SNF). 
 
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 you are medically stable and does not need a physician's supervision three times a week in an IRF. There are no acute rehabilitation nursing needs identified or documented. At the current 
functional level, the enrollee needs physical therapy and occupational therapy for a long time. The enrollee 
does not need intensive therapies consisting of at least three hours of therapy per day at least five days per 
week with multidisciplinary approach 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the tibia fracture treatment provided on 
May 12, 2022. 
 
You asked the Plan to waive the copayment for the tibia fracture treatment. You say that the treatment was 
needed due to an error during a previous procedure. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 $250 
copayment for other outpatient procedures and services performed in an outpatient hospital or ambulatory 
surgical center. 
 
You have been asked to pay a $250 copayment for the tibia fracture treatment. This item/service falls within 
the other outpatient procedures and services performed in an outpatient hospital or ambulatory surgical center 
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 the tibia fracture treatment 
provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
can be received in-network. 
 
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 18, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen treatment and an office visit to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve hyperbaric oxygen treatment and an office visit to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
hyperbaric oxygen treatment and an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous durable medical equipment (DME) provided 
on June 3, 2022, by a retail store. 
 
You asked the Plan to pay for miscellaneous DME from a retail store. You say that the items at issue were a 
medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for miscellaneous durable medical 
equipment (DME) provided on June 3, 2022, by a retail store.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 8, 2022. 
 
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 date of service was reported incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service for clinical laboratory tests 
must be the date that the specimen was collected.  
 
The specimens for these services were collected on March 2, 2022 and March 22, 2022. The date of service 
should not be April 8, 2022, which is the date the services were performed. 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 laboratory services provided to the enrollee on April 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the upper extremity CT scan provided on 
May 31, 2022. 
 
You asked the Plan to waive the copayment for the upper extremity CT scan. You say that the provider 
informed you that there would not be a copayment. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 
$139.32 copayment for diagnostic radiology services that are not ultrasounds. 
 
You have been asked to pay a $139.32 copayment for the upper extremity CT scan. This item/service falls 
within the diagnostic radiology services that are not ultrasounds 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. Per the EOC, there is a $350 copayment for 
diagnostic radiology services that are not ultrasounds. However, the allowed amount for this CT scan is 
$139.32, therefore you are only responsible for the lesser amount. Therefore, we decided that the Plan does not 
have to waive the copayment for the upper extremity CT scan provided on May 31, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve one additional hour per day, 7 days per week, of home health aide 
(HHA) services. 
 
You asked the Plan to pre-approve HHA services. The Plan denied your request. The Plan says that additional 
hours are considered custodial care, which is 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 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 HHA services. Our reviewer says that 
an additional hour per day of HHA service is medically necessary. Our physician reviewer found the clinical 
documentation shows that you have a progressive pulmonary condition and require increased assistance with 
non-custodial care services including positioning. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HHA services have been met. Therefore, we decided that the Plan has to pre-
approve one additional hour per day, 7 days per week, of home health aide (HHA) services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
February 22, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that this was your yearly 
mammogram and should not have a copayment. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
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 $75 
copayment for diagnostic procedures and tests, including ultrasounds. 
 
You have been asked to pay a $75 copayment for the diagnostic mammogram. This item/service falls within 
the diagnostic procedures and tests, including ultrasounds 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. The file shows that you have a personal history of 
breast cancer. For this reason, the procedure is considered diagnostic in nature. Therefore, we decided that the 
Plan does not have to waive the copayment for the diagnostic mammogram provided on February 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custodial-care home health services (S9122) provided from 
June 3, 2022, to July 16, 2022. 
 
You asked the Plan to pay for custodial-care services. You say that the requested services were a medical 
necessity for you. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial-care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for custodial-
care home health services (S9122) provided from June 3, 2022, to July 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 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 SNF care. Our reviewer says that the 
enrollee does not meet criteria for SNF admission. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide 
medically necessary and reasonable treatment. Records do not document the need for intravenous medications, 
new tube feeding, or ostomy care or daily complex wound care or respiratory care. Based on the medical 
records provided this enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and 
judgment of a qualified therapist are required to safely and effectively provide medically necessary and 
reasonable treatment. Based on the medical records provided there is no documentation that daily skilled 
services are required. The enrollee is walking household distances with a rolling walker (30 feet with no 
device) with contact guard assistance and is contact guard assist for transfers. Provided records do not 
document a significant decline in the enrollees functional status to necessitate daily inpatient skilled therapy 
services. Based on the medical records provided there is no documentation that the enrollee requires the 
services on an inpatient basis, only 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.