Persius/hicric huggingface dataset:
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 the enrollee had a fractured femur and an 
intramedullary nailing and still needs assistance from two people to walk or stand. You state the enrollee can 
only walk up to 40 feet and the enrollee is experiencing urinary retention that a catheter is needed for. You state 
that their blood pressure needs to be monitored closely due to increase issues. You state the enrollee has atrial 
fibrillation (A-fib) and is at high risk of stroke, new medications are being taken and the enrollee needs to be 
closely monitored. The Plan denied your request. The Plan says the stay is not medically necessary based on 
IRF criteria. The Plan states the enrollee's records also that they do not need an intensive team (rehabilitation 
doctor and nurse, social worker, and therapists) to oversee their care. The Plan states the enrollee can safely 
receive the services they need in other settings, for example: a skilled nursing facility, home with home health 
services or home with outpatient therapy. 
 
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 enrollee with right hip fracture, s/p surgery as described above, is medically 
stable and does not need physical medicine and rehabilitation (PM&R) physician supervision three (3) times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. An uncomplicated hip fracture patient, does not need intensive therapies, consisting of at least 3 
hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. IRF 
admission is not medically necessary based on lack of medical complexity, and lack of acute rehabilitation 
nursing needs. Document does not support the necessity for admission to an IRF. While the enrollee may 
benefit from physical therapy (PT) and occupational therapy (OT), the enrollee's rehabilitation needs can be 
safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF). 
 
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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit (99215) provided on May
24, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office or other outpatient visit. You say that you would like this claim
reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not
obtained for these services rendered by an OON 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 the office or other outpatient visit (99215) provided on May 24, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee continues to require acute care services including intravenous antibiotics 
and dressing changes. The enrollee continues to receive acute care services, and these have not been denied. 
The enrollee does not require services that he is not currently receiving but that would be available at the 
LTACH facility. 
 
 
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breathing capacity test (94010) 
provided on September 13, 2021. 
 
You asked the Plan to waive the copayment for the breathing test. You say that you were told you would not 
owe a copayment for this service. The Plan denied your request. The Plan says this claim was processed 
correctly, and your copayment was assessed in accordance with your contract. The Plan also reviewed your call 
logs and found that you only called the Plan after the date of service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for other outpatient diagnostic tests - non-radiological diagnostic services.  
 
You have been asked to pay a $30 copayment for the breathing test. The breathing test falls within the other 
outpatient diagnostic tests - non-radiological diagnostic 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 breathing capacity test 
(94010) provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for wound care. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are other participating providers in the area. 
 
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 
an out-of-network referral for wound care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rehabilitation services (H2017) provided on August 23, 
2021, to October 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rehabilitation services. You say that you would like these claims reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says prior authorization was not 
obtained for these services rendered by an OON 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 the rehabilitation 
services (H2017) provided on August 23, 2021, to October 1, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are receiving appropriate care at the present acute care hospital. There are no 
services available at the LTACH that you require that are not available at the health care setting being offered 
by the health plan. 
 
 
 
  
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 pay for the additional supplies (99072) provided on July 20, 2021.
You asked the Plan to pay for the additional supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99072 has a status indicator of B.
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, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the record. Specifically, CPT code 99072 has a status indicator of B. This means that the payment for CPT code 99072 is bundled into the payment for another procedure or service. Based on this information, we decided that Medicare rules for coverage of the additional supplies have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies (99072) provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the scanning of computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) rendered on August 10, 2021.
You asked the Plan to waive the copayment for the scanning of computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve. You say that you were billed $26.47 after you paid your bill for $45. You also say you received two bills stated there was a $0 copayment. The Plan denied your request. The Plan says you were 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 enrollees must pay a $45 copayment for specialist physician services. Your contract with the Plan also says that additional cost-sharing applied for diagnostic and radiology services received at physician offices. Your contract with the Plan also says that enrollees must pay a $50 copayment for all other Medicare-covered outpatient diagnostic tests. You have been asked to pay $26.47, which is less than the $50 copayment for the scanning of computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve. The scanning of computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve 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 the scanning of computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) rendered on August 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound coded as 76700 provided on October 11, 2021.
You asked the Plan to pay for the abdominal ultrasound. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier required for payment.
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 76700 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound coded as 76700 provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve the dental item. You say that your dentures were not made correctly. You say that they never fit despite being adjusted 4 times. You say that you are not able to eat anything of substance since you have not top teeth. You also say that you cannot pay for dentures out of pocket. The Plan denied your request. The Plan says the frequency limit for a complete upper denture has been reached.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and complete upper denture is listed as covered, the frequency limits of 1 every 5 plan years has been reached. The record shows that the Plan paid for a complete upper denture that you received on June 25, 2018. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pharmacogenomic testing (81401, 81479, 81225, 81227, 81226,
81230, 81231, 81241, 81291, 81328 and 81355) provided on September 15, 2021.
You asked the Plan to pay for the pharmacogenomic testing. You say that you would like reconsideration
because this claim was billed correctly. The Plan denied your request. The Plan says that these services were
not billed 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, the Plan has not forwarded any indication as to why these services
were billed incorrectly. 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. Therefore, we decided that the Plan has to pay for the
pharmacogenomic testing (81401, 81479, 81225, 81227, 81226, 81230, 81231, 81241, 81291, 81328 and
81355) provided on September 15, 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 pre-approve oncology (prostate) gene expression profile by real-time 
RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score (CPT code 0005U). 
 
You asked the Plan to pre-approve the laboratory services. You say that the service is necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show you 
have had a previous prostate biopsy. 
 
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 laboratory services. Our physician 
reviewer found the EPI test is a non-invasive, non-DRE requiring, urine-based, liquid biopsy test intended for 
men 50 years of age and older who have an elevated Prostate Specific Antigen (PSA) level between 2  10 
ng/mL and who are being considered for a prostate biopsy. In this case, the enrollee had a negative prostate 
biopsy. The review has determined that the medical records provided do not meet the requirements listed in the 
LCD for Medicare coverage. 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes 
(ERG, PCA3, and SPDEF), urine, algorithm reported as risk score (CPT code 0005U).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided on October 5, 2021. 
 
You asked the Plan to waive the copayment for an EKG. You say that an EKG is not being covered and you 
disagree. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 $30 
copayment for non-radiological diagnostic services. 
 
You have been asked to pay the allowed amount of $16.38, which is less than the $30 copayment for an EKG. 
An EKG 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 an EKG provided on October 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the enrollee's records do not show that you require daily skilled services that can 
only be provided on an inpatient basis. The Plan states the services you require, such as additional therapy 
services, can safely be received at a different setting, for example, home with home health, in residential care, 
or home with close follow-up with your doctor. 
 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 daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. 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 SNF 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 SNF care.