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

 
We decided that the Plan does not have to pay for the ER visit provided on April 2, 2021. 
 
You asked the Plan to pay for the ER visit. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ER visit provided on April 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for IRF admission and 
services. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, 
multidisciplinary approach to daily therapy. The records do not support the enrollee's ability to tolerate an 
intensive rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 days per 
week. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care such as 
at a skilled nursing facility, on an intermittent basis at home with home health care, or in a long-term care 
setting. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are 
no complex nursing or rehabilitation needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee 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 the IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on February 17, 
2022, to February 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that the appellant is requesting 
reconsideration stating that the member would not have been admitted a second time if they would have kept 
her the first time. The POA is stating that they should not be responsible for a second inpatient cost. The Plan 
denied your request. The Plan says the cost-sharing 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for per day, days 1 to 5 for inpatient hospital. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. There were 5 days, resulting in a total cost-share amount of $1,250.  
 
 
 The enrollee has been asked to pay a $250 copayment for inpatient hospital stay. Inpatient hospital stay falls 
within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay on February 17, 2022, to February 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to waive the out-of-network cost share and apply the in-network cost share 
amount for the evaluation and management services provided on September 22, 2021. 
 
You asked the Plan to waive the out-of-network cost share and apply the in-network cost share. You say that 
you would like reconsideration because you believe these were processed at the out-of-network rate in error. 
The Plan denied your request. The Plan says that this claim processed correctly. 
 
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, you have argued that in-network care was not available to treat 
your condition. The Plan has not addressed your argument. Additionally, the Plan has approved the same care 
for later dates of service, indicating that in-network care was not available. 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 waive the out-of-network cost share and apply the in-
network cost share amount for the evaluation and management services provided on September 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered January 5, 2022. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the records show that the definitive 
confirmation testing was medically necessary for only two drug classes. In all cases, the number of drug classes tested should reflect only those likely to be present based on the medical history, current clinical presentation, 
and the illicit drugs that are in common use. The records do not support that the testing was reasonable and 
medically necessary for the enrollee. 
 
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 pay for the definitive drug testing rendered January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ExoDx Prostate IntelliScore (EPI) testing. 
 
You asked the Plan to pre-approve EPI testing. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the denial of authorization for this testing is correct, because your prostate specific 
antigen (PSA) has not been elevated above 3. 
 
The Plan follows Medicare rules. Medicare rules state that biomarker testing such as ExoDx Prostate 
IntelliScore is only covered under certain circumstances. 
 
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 EPI testing. Our reviewer says that you 
do not meet the Medicare criteria for the requested testing. Our physician reviewer found the record does not 
show that you have an elevated prostate specific antigen (PSA) level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EPI testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ExoDx Prostate IntelliScore (EPI) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for biopsy on April 26, 2022. 
 
You asked the Plan to waive the copayment for biopsy. You say that this visit did not include a hospital visit. It 
was all done at a clinic. The Plan denied your request. The Plan says the cost-sharing 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 a $150 
copayment for Medicare-covered outpatient hospital surgery services. We cover medically-necessary services 
you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered 
services include but are not limited to: Services in an emergency department or outpatient clinic, such as 
observation services or outpatient surgery. 
 
 
 
 You have been asked to pay a $150 copayment for biopsy. Biopsy falls within the Outpatient hospital services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for biopsy on April 26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the testing (81455) provided on October 28, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the services must be 
billed with code 0037U. 
 
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. The Plan argues that, per NCD 90.2, the requested testing must be billed with 
code 0037U for payment to be considered. However, review of NCD 90.2 does not show that the requested 
testing must be billed with a specific code for coverage. The Plan has not provided documentation supporting 
its denial. Therefore, we decided that the Plan has to pay for the testing (81455) provided on October 28, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing provided on February 24, 2022. 
 
You asked the Plan to pay for PrismRA. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that testing must be FDA approved in order to be 
covered.  
 
We looked at the file and Medicare rules. Review of the file does not support that the PrismRA testing 
provided is FDA approved. Based on this information, we decided that Medicare rules for coverage of 
PrismRA have not been met. Therefore, we decided that the Plan does not have to pay for the PrismRA testing 
provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 11, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement in place that the codes 
billed are included in the dialysis rate. The Plan denied your request. The Plan says the services are the 
responsibility of the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after July 11, 2022. 
 
You asked the Plan to pre-approve SNF care after July 11, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 after July 11, 2022. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued SNF care. Our physician 
reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does 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 SNF care after July 11, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat transforaminal epidural steroid injection (TFESI) 
services. 
 
You asked the Plan to pre-approve the repeat TFESI services. You say that you need the requested injection 
services because your back is in extreme pain. You say that you fell and that something is wrong with it from 
the top of your neck to the back of your spine. The Plan denied your request. The Plan says the request is not 
medically necessary because the records show that the enrollee has not had at least 3 months of 50% sustained 
improvement in pain, nor is your doctor planning a different approach, different medication, or level. 
 
The Plan follows Medicare rules. Medicare rules say that ESI services are considered medically necessary 
when there has been a failure to respond to 4 weeks of noninvasive conservative care. Medicare rules also say 
that repeat ESI services are covered when the first injection produced at least 50% sustained improvement in pain relief or improvement in function for at least 3 months.  
 
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 repeat TFESI services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
chronic low back pain and lumbar radiculopathy. The enrollee has not done physical therapy. A prior 
transforminal L4-L5 Epidural Steroid injection on June 7, 2022, produced only 20% pain relief. 
 
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 repeat TFESI services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve repeat transforaminal epidural steroid injection (TFESI) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 28, 
2022, to March 17, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says enrollee was medically stable for discharge to home or 
lower level of care as of February 25, 2022. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found records from February 16, 2022 showed the enrollee was stable and appropriate for a 
lower level of care or home with hemodynamic stability, overall improvement with treatment back to baseline 
cognition, and ability to participate in physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on February 28, 2022, to March 17, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on October 15, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that at the time these services were rendered, your 
office was not aware that authorization was required for Outpatient Clinic Services. The Plan denied your 
request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that there 
is no record of a request for prior authorization prior to offering these 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 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 imaging services provided on October 15, 
2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on October 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on October 21, 2021. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed items/services were provided twice on the same date. Based on 
this information, we decided that the Medicare rules for the services have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the services (99285) provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CT placement for needle guidance 
provided on March 9, 2022. 
 
You asked the Plan to waive the coinsurance for CT placement for needle guidance. You say that you have 
received numerous bills and charges and you feel there should only be a single bill. The Plan denied your 
request. The Plan says the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered therapeutic radiology services, which includes technician materials and 
supplies. 
 
 
 
 
 You have been asked to pay $13.69 which is 20% of the allowed amount for CT placement for needle 
guidance. The allowed amount is $68.45 (20% x $68.45= $13.69). CT placement for needle guidance falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and 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 CT placement for needle guidance provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the billed codes are 
included in the dialysis rate. The Plan denied your request. The Plan says the services are the responsibility of 
the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 5, 2022.