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

 
We decided that the Plan does not have to reduce the copayments for substance abuse office visits provided 
from September 15, 2021, to September 30, 2021. 
 
You asked the Plan to reduce the copayments for substance abuse office visits. You say that your copayment 
should be $40 for mental health services. 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 a $45 
copayment for in-network outpatient substance abuse services.  
 
The visits you had are considered substance abuse services, not mental health services. You had visits on 
September 15, 2021, September 27, 2021, and September 30, 2021. You have been asked to pay a total of $135, which is a $45 copayment for each substance abuse office visit ($45 copayment x 3 visits = $135). 
Substance abuse office visits falls within the Outpatient Substance Abuse 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 reduce the copayments for substance abuse office visits provided from September 15, 
2021, to September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of dialysis services with an out-of-
network (OON) provider. 
 You asked the Plan to pre-approve dialysis services. You say that it is medically necessary for the enrollee to 
continue receiving care from the OON provider. The Plan denied your request. The Plan says there is no 
medical reason why the enrollee would not be able to utilize an in-network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 dialysis services. Our reviewer says that 
the requested continuation of care is not medically reasonable and necessary. Our physician reviewer found 
that the patient is a 49-year-old male with end stage renal disease. A request was made for continuity of care 
with an out of network dialysis provider. The notes describe the patient as struggling with non-compliance with 
dialysis and refuses other treatments. The records did not clearly explain why the patient would not be able to 
or appropriate to see an in-network dialysis provider to continue treatment. Therefore, without sufficient 
support provided, this request for continuing care with an out-of-network provider will be considered 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 dialysis services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the continuation of dialysis services with an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening mammography (77067) and breast ultrasound 
(76641) and screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary 
procedure) (77063) provided October 25, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that this was for your annual mammogram and 
breast sonogram. It is covered under your Plan, whether in or out of network. The Plan denied your request. 
The Plan says services were received from a provider who had opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for screening 
mammography (77067) and breast ultrasound (76641) and screening digital breast tomosynthesis, bilateral (list 
separately in addition to code for primary procedure) (77063) provided October 25, 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 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 appear to be improving and more stable and should require only short-term 
additional acute care services that can safely be administered at the current facility. There are no services at the 
LTACH that you require that are not already available and covered at the current facility. Transfer to a lower 
level of care may be considered when treatment has completed. 
 
 
 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: Favorable

 
We decided that the Plan has to pre-approve a colonoscopy, flexible; diagnostic, including collection of 
specimen(s) by brushing or washing (45378). 
 
You asked the Plan to pre-approve a colonoscopy. You say that a colonoscopy is medically necessary. The Plan 
denied your request. The Plan says that a colonoscopy is not medically necessary. This is based on the current 
2021 tri-society guidelines and the American Gastroenterological Association that the colonoscopy is not 
warranted until the 10-year interval. 
 
The Plan follows Medicare rules. Medicare rules say one of the characteristics of the high risk individual is a 
personal history of adenomatous polyps. 
 
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 a colonoscopy. Our reviewer says that 
the requested colonoscopy is considered medically reasonable and necessary in this case. Our physician 
reviewer found the follow-up surveillance of prior adenomatous colon pathology is considered by Medicare as 
a "High Risk Screening" procedure. The LCA approves coverage of follow-up colonoscopy every 2 years for a 
patient with a prior history of an adenomatous polyp. 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a colonoscopy have been met. Therefore, we decided that the Plan has to pre-
approve a colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing 
(45378).  
 
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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require 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 of therapy per 
day at least 5 days per 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. Therapy services may be provided 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim provided lists a place of service as an independent laboratory. If 
an independent lab bills for services, the place where the sample was taken is reported as the place of service. 
The records do not show that the specimen was obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on June 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, or ostomy care or daily complex wound care. You are walking household 
distances with a rolling walker with stand-by assistance and is stand-by assist for transfers. You do not require 
the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility 
on a part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided by a Licensed Professional 
Counselor on July 29, 2021. 
 You asked the Plan to pay for these services. You say that you had a referral for these services. The Plan denied 
your request. The Plan says your physician did not confirm that you had a referral and the provider used is not 
a Medicare eligible provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers and Medicare eligible 
providers. The contract with the Plan says enrollees must use network providers.  
 
You received services out of network, without prior authorization, from a provider who is not a Medicare 
eligible provider. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for out of network services provided by a Licensed Professional 
Counselor on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided June 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the place of service listed on 
the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81479) provided June 17, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services provided from May 16, 2020, to May 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that 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 diagnosis code 96.01. 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. Our reviewer says that the use of diagnosis code 96.01 is 
supported by the records provided. Our physician reviewer found that the enrollee is a 71-year-old female with 
COPD, sleep apnea, and lung cancer who was admitted/transferred following intubation for airway protection 
due to angioedema related to allergic reaction to lisinopril. She was treated with mechanical ventilation, 
steroids, and pulmonary toilet. The enrollee required ventilator assist control 14 tidal volume 360 5+5 PEEP 
40% min volume at 6-7 L mean airway pressure 9 to stabilize her breathing. Respiratory rate was elevated prior 
to intubation. She was sedated on ventilator support. Due to the enrollee requiring mechanical ventilation and 
high dose oxygen support and sedation in order to stabilize respiratory status, this describes acute respiratory 
failure as documented. Therefore, this diagnosis is appropriate for this admission and is supported by the 
documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient services provided from May 16, 2020, to May 22, 2020.  
 
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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require 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 of therapy per 
day at least 5 days per 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transport provided on May 28, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wheelchair van transport. You say that you want to be reimbursed for the 
charge. 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 
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 wheelchair van transport provided on May 28, 
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 fluoroscopic guidance used for needle placement on 
August 11, 2021, billed with code 77003. 
 
You asked the Plan to pay for the services as billed. You say that this was correctly billed as this guidance was 
necessary to perform the injection. The Plan denied your request. The Plan says this is an add-on code that 
requires specific primary codes to be paid. This was not billed with an appropriate primary code. 
 
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 77003 
is an add-on code and has not been billed with an appropriate primary procedure code. 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 fluoroscopic guidance used for needle placement on August 11, 2021, billed with code 77003.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from October 4, 2021, to 
October 29, 2021. 
 
You asked the Plan to pay for acupuncture services. You say that the services that were rendered were 
medically necessary. The Plan denied your request. The Plan says the enrollee has received the maximum 20 
covered acupuncture treatments in 2021. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Plan has paid for 20 acupuncture visits prior to 
the October 4 visit. The services that occurred beyond the allowed 20 visit maximum are not covered. 
Therefore, we decided that the Plan does not have to pay for acupuncture services provided from October 4, 
2021, to October 29, 2021.