Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health service provided on August 31, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a home health service. You say that it was medically necessary to see the 
enrollee and the claim should be paid. The Plan denied your request. The Plan says the rendering and referring 
providers are out-of-network providers with no approved authorization. Also, the services rendered were not 
urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health service provided on August 31, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for X-rays of the chest provided on June 29, 
2021. 
 
You asked the Plan to waive the deductible for the X-rays. You say that the bill was sent to you late and you 
did not receive clarification from the billing office. The Plan denied your request. The Plan says the correct 
amount was applied to your deductible. 
 
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 $750 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the X-rays wereprovided on June 29, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for X-rays of the chest provided on 
June 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires mid-to-long-term 
acute care in a facility that can tend to medically complex patients on an ongoing basis. You say that it is your 
obligation and professional opinion that the requested venue is appropriate given the enrollee's extensive 
length-of-stay in the current short-term acute care hospital. You say that the enrollee requires the more 
specialized treatment of the LTACH and is too complex for skilled nursing care at this time. The Plan denied 
your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's 
needs can be met at an alternate level of care. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital.  
 The enrollee does not require services at the LTACH that are not available at the acute care hospital where he 
is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical summary and documentation 
support the request for LTACH care. You say that the enrollee is stable at this time and her needs would be 
best service in an LTACH hospital until she can safely discharge to a lower level of care. The Plan denied your 
request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's needs 
may be met in the current hospital setting. 
 
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 there is no documentation provided indicating medical necessity for admission to 
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical consultation services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve medical consultation services. You say that this care is medically necessary. 
The Plan denied your request. The Plan says there are in-network providers available to meet the enrollee's 
medical needs. 
 
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 
medical consultation services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan 
provided on September 26, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you were never told the copayment 
would be this amount. The Plan denied your request. The Plan says the proper copayment was applied for this 
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 $275 
copayment for Medicare-covered diagnostic radiology services.  
 
  You have been asked to pay a $275 copayment for a CT scan. A CT scan 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 copayment 
for a computerized tomography (CT) scan provided on September 26, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
August 30, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that that you were advised to 
go to the emergency room and were told it would be covered with no copayment. The Plan denied your request. 
The Plan says the proper copayment was applied, and the coronavirus cost share waiver ended on May 31, 
2021. 
 
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 $90 
copayment per visit for emergency care.  
 
  You have been asked to pay a $90 copayment for an emergency room visit. An emergency room 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 visit provided on August 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH. You say that the enrollee meets LTACH admission criteria, and his ongoing medical 
care warrants an LTACH level of care to achieve a safe and sustainable discharge. The Plan denied your 
request. The Plan says LTACH care is not medically necessary. The Plan says that the care needed can safely 
be provided in a skilled nursing facility. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not 
meet Medicare criteria for coverage of the IRF 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. Our physician reviewer found the documentation is insufficient to demonstrate that the enrollee requires an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The documentation does not 
support that the enrollee requires at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of 
therapy services.  It is not clear that the enrollee is reasonably expected to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF.  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the X-ray exam of chest (71045) provided on February 
19, 2021. 
 
You asked the Plan to pre-approve the X-ray exam of chest. You say that this was billed correctly and should 
be reprocessed. The Plan denied your request. The Plan says this was billed with an incorrect point-of-service 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code for hospital patients should be 
either inpatient or outpatient regardless of where the encounter takes place. 
 
The file shows that the enrollee was an inpatient at the time of this imaging service. As such, the reported 
outpatient POS code is not correct. Therefore, we decided that the Plan does not have to pre-approve the X-ray 
exam of chest (71045) provided on February 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 
You asked the Plan to pre-approve epidural steroid injection services. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that for epidural steroid injections to be covered, the 
patient should be part of an active rehabilitation program, home exercise program or functional restoration 
program 
 
We looked at the file and Medicare rules. There is no evidence provided that the patient is currently involved in 
an active rehabilitation program, home exercise program or functional restoration program. Based on this 
information, we decided that Medicare rules for coverage of epidural steroid injection services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injection services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomographic angiography 
(CTA), chest (71275), magnetic resonance (eg, proton) imaging (MRI), brain (70551), and echocardiography 
(ECG) (93306), provided on October 11, 2021, through October 12, 2021. 
 
You asked the Plan to waive the copayment for the CTA, MRI and ECG. You say that you should not be 
responsible for these services. The Plan denied your request. The Plan says the cost share was applied 
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 
advanced imaging copay and a 20% diagnostic procedures and test coinsurance for outpatient hospital services.  
 You have been asked to pay a $250 advanced imaging copay and a 20% diagnostic procedures and test 
coinsurance for the CTA, MRI and ECG. These services fall 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 the computed tomographic angiography (CTA), 
chest (71275), magnetic resonance (eg, proton) imaging (MRI), brain (70551), and echocardiography (ECG) 
(93306), provided on October 11, 2021, through October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen 
concentrator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that oxygen equipment 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of COVID-19 
pneumonia. Walking oximetry on December 25, 2021 showed blood oxygen saturation (SpO2) decreasing to 
86 percent with walking, but testing with supplemental oxygen was not done. The criteria for coverage are not 
met; therefore, the oxygen equipment 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an oxygen concentrator and portable oxygen concentrator.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
August 26, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were advised to go 
to the emergency room and were told it would be covered with no copayment. The Plan denied your request. 
The Plan says the proper copayment was applied, and the coronavirus cost share waiver ended on May 31, 
2021. 
 
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 $90 
copayment per visit for emergency care.  
 
  You have been asked to pay a $90 copayment for an emergency room visit. An emergency room 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 visit provided on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 18, 2021, 
to July 20, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.21, defined as acute 
and chronic respiratory failure with hypoxia, and J96.22 defined as acute and chronic respiratory failure with 
hypercapnia. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the services provided. Our physician 
reviewer found that the enrollee has a history of asthma and chronic obstructive pulmonary disease. He reports 
feeling significantly better after receiving nebulizer treatments. Although acute on chronic respiratory failure 
with hypoxia and hypercapnia was documented, reasonable support within the health record must be present 
for that diagnosis. The review has determined that that the billed diagnoses were not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from July 18, 2021, to July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0481) rendered by the out-of-network (OON) provider on August 11, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0481) rendered by the out-of-network (OON) provider on August 11, 2021.