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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necesasry for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 
requested SNF care is not medically reasonable and necessary. Our physician reviewer found that the enrollee 
is a 72-year-old male status post left above the knee amputation, diabetes and peripheral vascular disease, 
currently in an inpatient rehabilitation facility. In this case, there are no identifiable skilled nursing service 
needs. While there are identifiable skilled therapy service needs, these services are not required on a daily 
basis. In conclusion, 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfer to 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 stay is not medically necessary based on SNF criteria. 
 
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 physician reviewer 
found there is no evidence that a SNF-to-SNF transfer is medically necessary or reasonable. There is no 
evidence that the current SNF facility is unable to provide the required services. Transfers for the patient or 
family convenience or preference are not considered 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve transfer to SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable as billed.  
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. Although code 86920 was billed on a separate claim, this service was 
provided on the same date by the same facility as the other codes. We find that it is not reasonable to allow two 
separate payments for services provided on the same date simply because the provider elected to bill them on 
two claims instead of a single claim. As all of the codes at issue, with the exception of 36415, are assigned 
status indicator Q1, we find that the Plan was correct to recoup payment for the claim with codes 86901, 
86850, 86900, and 36415. This is because when only Q1 services are billed, payment may only be made for the 
code with the highest reimbursement rate, which is code 86920. Therefore, we decided that the Plan does not 
have to pay for the services provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and you are the 
sole provider of this test. The Plan denied your request. The Plan says unauthorized, non-plan care is not 
covered. 
 
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 lab services provided on February 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for out of network office visit provided on 
April 4, 2022. 
 
You asked the Plan to waive the deductible for out of network office visit. You say that you do not owe this 
amount that you already paid $5 copayment at time of service. The Plan denied your request. The Plan says the 
deductible applied is correct. 
 
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 out of network office visits.  
 
 
 
 
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $750 deductible which applies to Physician/Practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
out of network office visit was received on April 4, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for out of network office visit provided on April 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an 
ambulatory surgery center on March 15, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you had this same 
procedure in November and didn't have to pay a copayment. The Plan denied your request. The Plan says you 
were charged this copayment 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 $200 
copayment for outpatient surgery and services provided at an ambulatory surgical center.  
 
You have been asked to pay a $200 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy 
falls within the outpatient surgery and services provided at an ambulatory surgical center benefit category. This 
copayment applies regardless of what you may have paid for similar services in the past. 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 diagnostic colonoscopy you had at an ambulatory surgery center 
on March 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from March 
3, 2022, to April 1, 2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee's Medicaid benefits have paid for these 
services, and their Medicare benefits should pay as well. The Plan denied your request. The Plan says the 
criteria for SNF care were not met, as the enrollee did not require the intensity of services provided at this level 
of care. 
 
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 pay for SNF care. Our reviewer says that the SNF 
services were not medically necessary on the dates in question. Our physician reviewer found that the enrollee 
received oral medications and had stable vital signs and good oral intake. There are no identifiable skilled 
nursing service needs which require the specialized skill, knowledge and judgement of a skilled professional 
nurse to safely and effectively provide medically necessary treatment. Regarding rehabilitation services, the 
enrollee did not receive nor require skilled therapy for the dates in question and was independent with 
functional mobility and activities of daily living. There are no identifiable skilled therapy service needs which 
require the specialized skill, knowledge and judgement of a qualified therapist. The enrollee did not require 
skilled nursing or therapy services on a daily basis and did not meet the 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 have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided from March 3, 2022, to April 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on October 14, 2021, to October 
29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services were not emergent in nature. 
 
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 hospital services provided on October 14, 2021, to 
October 29, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and hemoglobin glycosylated A1C testing 
provided on February 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and hemoglobin glycosylated A1C testing. You say that you were 
told by the doctor's office that they do not take his insurance. You say you were told by the doctor's office that 
they would write off the cost. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
office visit and the hemoglobin glycosylated A1C testing. We found no exception that would require the Plan 
to pay the office visit and the hemoglobin glycosylated A1C testing.  Therefore, we decided that the Plan does not have to pay for the office visit and hemoglobin glycosylated A1C 
testing provided on February 23, 2022, 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 emergency room services provided from 
January 10, 2022, to February 1, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you would like 
reimbursement of medical services received while out of the country. 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 you must pay a $500 
copayment for each emergency service, urgent service, and emergency transportation outside the United States. 
 
You have been asked to pay $180, which is less than the $500 copayment for emergency room services on 
January 10, 2022. You have also been asked to pay $340, which is also less than the $500 copayment for 
emergency room services on January 16, 2022. You have also been asked to pay $180, which is also less than 
the $500 copayment for emergency room services on February 1, 2022. Emergency room services fall 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 emergency room 
services provided from January 10, 2022, to February 1, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee can receive further services at a lower 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with polyp removal 
performed on February 24, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that the service should be considered 
preventive. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay no 
coinsurance, copayment, or deductible for screening exam. The outpatient hospital services or outpatient 
surgery cost share will apply when a polyp removal or biopsy is conducted during a preventive screening. 
 Your contract with the Plan also clearly says that you must pay a $325 copayment for each hospital outpatient 
surgical facility visit. 
 
You have been asked to pay a $325 copayment for the colonoscopy. The colonoscopy falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 colonoscopy with polyp 
removal performed on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that you were unaware you needed authorization 
to see this provider. You say it is the provider's responsibility to get authorization and you should only be 
responsible for the copayment. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
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 
podiatry services. We found no exception that would require the Plan to pay for the podiatry services. The 
records provided for review do not show that the podiatry visit was urgent or emergent. Therefore, we decided 
that the Plan does not have to pay for podiatry services provided on March 1, 2022, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve automatic positive airway pressure (APAP) for the 
enrollee. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the medical records available does not support the medical necessity of this 
request. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that auto-titrating continuous positive airway pressure (CPAP) is considered not medically necessary 
because it is not the appropriate treatment for this patient. The enrollee had previously diagnosed obstructive 
sleep apnea, although there are no details of the original diagnostic sleep study. A PAP titration on 12/14/18 
found that bilateral positive airway pressure (BiPAP) on 9/5 was effective, but the enrollee also has severe 
restless leg syndrome. The enrollee has had the device since then, but is having excessive daytime sleepiness, 
despite using it. There are no data downloads to confirm device use. There has been no replacement of mask or 
tubing. The enrollee should be provided with a new mask and supplies for the current device, and the use and 
effectiveness of the device assessed with a 30-day download and follow-up visit. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve automatic positive airway pressure (APAP) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care in effort to facilitate 
increased independence and return home and to their community with improved quality of life. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on IRF criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's nursing, medical and rehabilitation needs do require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee requires maximum 
assistance for dressing and toileting. The enrollee would likely be able to participate in and benefit from an 
intensive rehabilitation therapy program. Therefore, the IRF admission can be considered 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and 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.