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

We decided that the Plan does not have to pay for lab services (G0482) provided November 25, 2020.
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 services billed.
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 G0482 is drug testing, 15-21 drug classes.
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show at
least 15 drug classes were tested. 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
(G0482) provided November 25, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 19, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are
not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing
services received on July 13, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says acupuncture is only covered for low back pain.
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 only type of acupuncture that is covered is for
chronic low back pain. This requested service is an experimental acupuncture technique. Therefore, we decided
that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing services received
on July 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 23,
2021.
You asked the Plan to waive the copayment for ambulance services. You say that you were told that the
enrollee had to be rushed to the hospital only to be told at the hospital that nothing was wrong. The Plan denied
your request. The Plan says the claims were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $225 copayment for ambulance services.
The enrollee has been asked to pay a $225 copayment for ambulance services. Ambulance services fall within
the ambulance services benefit category. This means that the enrollee has 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
ambulance services provided on June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan
denied your request. The Plan says an IRF admission is not medically necessary and does not meet the
Medicare coverage 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 that based on the documentation provided, the health Plan's denial should be
upheld. You do not require the intensity of services provided at an IRF.
Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. Your care needs can be met at a lower level of care (ex. skilled nursing facility/sub-acute
rehabilitation).
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 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 you do not require intensive therapies, consisting of at least 3 hours of therapy per
day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from
continued physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and
low intensity setting such as in a skilled nursing 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 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: 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 does not meet
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 you do not require intensive therapies, consisting of at least 3 hours of therapy per
day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from
continued physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and
low intensity setting such as in a skilled nursing 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 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: 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 enrollee is not able to take care of herself and
requires 24-hour care. The Plan denied your request. The Plan says the denial of authorization for SNF care is
correct.
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 the enrollee does not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee was admitted for non-surgical management of a pelvic fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able 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 IRF admission and services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Positron emission tomography (PET) imaging (78813).
You asked the Plan to pre-approve the PET scan. You say that the enrollee's last imaging was done in May
2020 and you are requesting to have this PET scan approved. The Plan denied your request. The Plan says the
requested procedure is not the standard of care. A yearly renal ultrasound is the standard of care for the
enrollee's clinical condition.
The Plan must follow Medicare rules. Medicare rules say that only NaF PET/CT for initial treatment strategy
planning or subsequent treatment planning are covered. Surveillance NaF scans are not covered. Therefore, we
decided that the Plan does have to pre-approve a positron emission tomography (PET) imaging (78813).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve
Positron emission tomography (PET) imaging (78813)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions from an oral surgeon.
You asked the Plan to pre-approve these services. You say that you were referred to an oral surgeon because
you have high blood pressure. The Plan denied your request. The Plan says the services are not covered.
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. The Plan covers supplemental
dental benefits from a participating general dentist only.
We looked at this the file and Medicare rules. The file shows that you are requesting services from an oral
surgeon. Based on this information, we decided that the Plan's rules for coverage of these services have not
been met. Therefore, we decided that the Plan does not have to pre-approve dental extractions from an oral
surgeon.
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 does not meet
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 you do not require intensive therapies, consisting of at least 3 hours of therapy per
day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from
continued physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and
low intensity setting such as in the current skilled nursing facility or in home with therapies.
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: 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 does not meet
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 the enrollee does not require intensive therapies, consisting of at least 3 hours of
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee
may benefit from continued physical therapy, speech therapy, and occupational therapy, his rehab needs can be
safely met in an alternate and low intensity setting such as in a skilled nursing 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond December 16, 2021.
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the continued services are not medically necessary.
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 approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF for back pain caused by a herniated disc. She received oral medications and had stable vital signs. She received physical and occupational therapy in the SNF. By the dates in question, she needs stand-by to contact guard assist with bed mobility and transfers. She requires varied assist with activities of daily living. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the computed tomography (CT) scan of
the abdomen and pelvis with low osmolar contrast material you had on July 16, 2021.
You asked the Plan to waive the cost sharing for the CT scan and the low osmolar contrast material. You say
that you were told you wouldn't have to pay more than $130 for any radiology services. The Plan denied your
request. The Plan says you were charged this cost sharing correctly. The Plan says that phone records show that
when you called the Plan, you were advised that CT scans have a $155 copayment.
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 $155
copayment for radiological diagnostic services and 20% coinsurance for chemical agents used for diagnostic
procedures.
You have been asked to pay a $155 copayment for the CT scan and 20% coinsurance for the low osmolar
contrast material. The CT scan falls within the radiological diagnostic services benefit category and the low
osmolar contrast material is a chemical agent used during a diagnostic procedure. 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 cost sharing for the computed tomography (CT) scan of the abdomen and pelvis with low osmolar
contrast material you had on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on June 30, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the extremity study you had at a vascular
surgeon's office on July 26, 2021.
You asked the Plan to waive the copayment for the extremity study. You say that when you called for an
appointment with the doctor, the office did not have availability to do the extremity study and the consultation
on the same day unless you waited months. You went for the office visit on July 27, 2021, and you don't think
you should have to pay two separate copayments. 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 $35
copayment for outpatient diagnostic tests in a specialist's office.
You have been asked to pay a $35 copayment for the extremity study. The extremity study falls within the
outpatient diagnostic tests in a specialist's office benefit category. This copayment applies regardless of the
reason why you had to have this test on a separate date. 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 extremity study you had at a vascular surgeon's office on July 26, 2021.