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 you believe the enrollee's medical management and 
rehabilitation needs require an inpatient rehabilitation stay and close physician supervision. The Plan denied 
your request. The Plan says criteria for admission to the IRF setting have 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 enrollee has had multiple hospital stays over the past month secondary to 
infection and most recently presented with some vertigo and deconditioning. The enrollee is at minimal 
assistance level. The enrollee's post-acute functional status is at a modest decline in function. The enrollee's 
condition is one routinely managed at a level of care other than an IRF per evidence based and clinical practice 
standards. The enrollee does not have intensive or complex rehabilitation needs or require frequent physiatry 
oversight. 
 
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: 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 member requires an LTACH level of 
care. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current 
acute 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 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. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
 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 waive the cost share for outpatient diagnostic test provided on 
October 16, 2022. 
 
You asked the Plan to waive the cost share for outpatient diagnostic test. You say that you disagree with the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 a $750 deductible which applies to outpatient diagnostic tests/radiology 
services.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic 
tests/radiology services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $750 deductible which applies to outpatient diagnostic tests/radiology services. The total 
amount you are being asked to pay towards your $750 deductible is $173.20. This cost sharing is a contractual 
obligation that had not been met at the time outpatient diagnostic test was received on October 16, 2022. 
Therefore, we decided that the Plan does not have to waive the cost share for outpatient diagnostic test 
provided on October 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF services provided from May 13, 2022, 
to June 16, 2022. 
 
You asked the Plan to waive the copayment for SNF services. You say that you would like a reconsideration of 
the copayment for the SNF copayment. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $20 per 
day for days 1 to 20, a $80 copayment per day for days 21 to 44 and $0 copayment for days 45 to 100 for 
Medicare-covered SNF services.  
 
 
  You have been asked to pay a total copayment of $800 for SNF services ($20 per day x 20 days = $400 and 
$80 per day x 5 days = $400). This item/service falls within the Medicare-covered SNF 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 SNF services provided from May 13, 2022, to 
June 16, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on September 12, 2022. 
 
You asked the Plan to pay for ambulance transport. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance transport provided on September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the laboratory tests provided on August 
31, 2022. 
 
You asked the Plan to waive the copayments for the lab tests. You say that you have not had a copayment for 
lab services before. The Plan denied your request. The Plan says this cost sharing was charged 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 $5 
copayment for in-network Medicare-covered lab tests.  
 
You have been asked to pay a $3.72 copayment, which is less than the standard $5 copayment for the lab tests. 
You have also been asked to pay a $1.28 copayment, which is less than the standard $5 copayment for the lab 
tests. These items/services fall 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 copayments for the laboratory tests provided on 
August 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on July 1, 2022. 
 
You asked the Plan to pay for hospital services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided on July 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan, Computed tomography 
angiography (CTA) scan and an X-ray exam provided on July 30, 2022. 
 
You asked the Plan to pay for (CT) scan, (CTA) scan and an X-ray exam. The Plan denied your request. The 
Plan says Original Medicare is responsible for payment.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for computed tomography (CT) scan, Computed tomography 
angiography (CTA) scan and an X-ray exam provided on July 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 29, 2021. 
 
You asked the Plan to pay for lab services. You say that the claim needs to be reprocessed. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
   
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for lab services provided on July 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 25, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 
93976. 
 
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 76705 
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 procedure code 76705 billed for date of service May 25, 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 stay is medically necessary. The Plan denied 
your request. The Plan says 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three (3) visits weekly to regain or maintain the enrollee's functional status. 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 24, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on July 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF services provided from August 2, 
2022, to August 31, 2022. 
 
You asked the Plan to waive the copayment for SNF services. You say that you should not be responsible to 
pay this because the quality of the care was subpar. The Plan denied your request. The Plan says this cost 
sharing was charged 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). The enrollees contract with the Plan clearly says that for SNF care, 
enrollees must pay $20 per day for days 1 to 20 of a benefit period; $120 per day for days 21 to 44 of a benefit 
period; $0 per day for days 45 to 100 of a benefit period.  
 
You have been asked to pay $1,550 for SNF services. This is less than the standard $1,600 copayment ($20/day 
x 20 days = $400; $120/day x 10 day = $1,200. $400 + $1,200 = $1,600) because you had met your 2022 out-
of-pocket maximum with this amount. This item/service falls within the skilled nursing facility (SNF) care 
benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for SNF services provided from 
August 2, 2022, to August 31, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided from June 20, 2022, to August 4, 
2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you have provided medical records 
to support payment for this inpatient stay. The Plan denied your request. The Plan says that the enrollee's 
effective date with the Plan ended on June 30, 2022, and all of the inpatient days billed do not fall within the 
plan effective date.  The Plan says that a corrected claim needs to be submitted showing dates of service only 
until June 30, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare health plans must continue to cover, 
through discharge, inpatient services of a non-plan enrollee if the individual was an enrollee at the beginning 
of the inpatient stay. 
 
This is precisely the scenario in this case.  The enrollee was a member of the Plan on the date of admission to 
the inpatient hospital (June 20, 2022).  Medicare rules are clear that the Plan continues to be responsible for 
inpatient care until the date of discharge, regardless of the date of disenrollment.  The Plan has provided no 
other argument for non-coverage of these services, and there is nothing in the Medicare rules requiring a 
provider to rebill with a date of service only through the date of disenrollment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have been met. Therefore, we decided that the Plan has to pay for 
inpatient hospital services provided from June 20, 2022, to August 4, 2022.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are recommending an IRF based on the 
enrollee's current functional status, previous level of independence, need to optimize their functional level 
before starting any further cancer treatment, ability to tolerate an intensive rehabilitation program, medical 
needs and strong home supports. The Plan denied your request. The Plan says intensive rehabilitation service is 
not considered medically necessary for this enrollee. 
 
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 is frail and ill with cancer. The enrollee is not able to tolerate 
intensive therapy. The enrollee is functioning at a level that does not require intensive rehabilitation to improve 
as he is walking 80 feet with contact guard assist. Intensive therapy services are not indicated. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve SSBCI benefits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the  additional 10 occupational therapy (OT) visits. 
 
You asked the Plan to pre-approve the  OT services. You say that the enrollee is at a risk of decreased range of 
motion and increased pain due to her multiple comorbidities. The Plan denied your request. The Plan says the 
notes do not show the enrollee needs the ongoing skills of an occupational therapist. 
  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 OT. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the most recent documentation indicated that the enrollees cervical spine range 
of motion has not changed, and their pain level has not significantly changed. While it is understandable that 
this may provide pain relief, there is a lack of medical literature indicating that this provides superior outcomes 
when compared to a home exercise program or modalities that do not require the skills of an occupational 
therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the  additional 10 occupational therapy (OT) visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided by 
an in-network provider on August 8, 2022. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG). You say that you do not think 
you should owe anything for this service. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $20 
copayment for in-network Medicare-covered non-radiological diagnostic services, which includes 
electrocardiograms (EKGs). 
 
 
 
 You have been asked to pay a $12.91 copayment for the electrocardiogram (EKG) because the allowed amount 
for this service is less than the $20 copayment. This item/service 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 electrocardiogram (EKG) provided by an in-network provider on August 8, 2022.