Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states your 
records show that your care is routine in nature, and you do not need a team of providers. The Plan states you 
can safely receive the services you need in other settings, for example: a skilled nursing facility, home with 
home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found you are medically stable and do not need physical medicine and rehabilitation 
(PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. An uncomplicated hip fracture patient, at the 
current functional level, does not need intensive therapies, consisting of at least 3 hours of therapy per day at 
least five (5) days per week with multidisciplinary approach to daily therapy. IRF admission is not medically 
necessary based on lack of medical complexity, and lack of acute rehabilitation nursing needs and current 
functional level. The documents do not support the necessity for admission to an IRF. While you may benefit 
from physical therapy (PT) and occupational therapy (OT), your rehabilitation needs can be safely met in an 
alternate and low intensity setting such as in an SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212) provided on April 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because authorization was requested and you were referred to this provider. The Plan denied your request. The Plan says this office visit was not urgent, emergent or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99212) provided on April 8, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an infliximab-dyyb, biosimilar, (inflectra)
injection (Q5103) and a normal saline solution infusion (J7050) rendered on October 20, 2021.
You asked the Plan to waive the coinsurance for an infliximab-dyyb, biosimilar, (inflectra) injection and a
normal saline solution infusion. You say that you were told the doctor's office had spoken to the Plan and
someone at the Plan had told them that you had already met your deductible for this year and there would be no
charge for these infusions, and then next year it would be the same after you met your deductible again. 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 20%
coinsurance for each Medicare Part B prescription drug.
You have been asked to pay $329.65, which is 20% coinsurance of the allowed amount for an infliximab-dyyb, biosimilar, (inflectra) injection and a normal saline solution infusion ($1,648.25 allowed amount x 20% coinsurance = $329.65). Infliximab-dyyb, biosimilar, (inflectra) injections and normal saline solution infusions fall within the Medicare Part B prescription drugs 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 coinsurance for an infliximab-dyyb, biosimilar, (inflectra) injection (Q5103) and a normal saline solution infusion (J7050) rendered on October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from
September 21, 2021, to September 23, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you changed
insurance plans and feel that you are being penalized with additional charges. 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 $750
copayment for each inpatient stay for unlimited days.
You have been asked to pay a $750 copayment for the inpatient hospital services. The inpatient hospital
services fall within the Inpatient Hospital 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 inpatient hospital services provided from September 21, 2021, to September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
 
 
 
 We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states physical 
therapy at a skilled nursing facility may be covered if requested. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. You continue to 
have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement; 
however, the documentation does not support that you would meet criteria for admission to an acute IRF. There 
is no indication that you would require or be able to participate in skilled rehabilitation in an IRF, participating 
in rehabilitation services fifteen (15) hours a week, under the supervision of a physician with at least three (3) 
visits weekly to regain or maintain your functional status. You 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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic behavior services (H2019) and  psychosocial 
rehabilitation services (H2017) provided on July 1, 2021, to October 1, 2021m by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for therapeutic behavior services and psychosocial rehabilitation services. You say 
that you are appealing with supporting records. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider with the Plan and there is not a referring provider. The Plan also says 
that they have also determined that these services are not urgent or emergent, nor were they approved in 
advance.  
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 therapeutic behavior services (H2019) and  
psychosocial rehabilitation services (H2017) provided on July 1, 2021, to October 1, 2021m by an out-of-
network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on September 23, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP or clinical social worker will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on September 23, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayments for physical therapy telehealth visits provided on
October 19, 2020, and October 26, 2020.
You asked the Plan to waive the copayments for physical therapy telehealth visits. You say that the physical
therapy visits were telehealth visits. You also say that the Plan waived out of pocket costs for telehealth visits
to help reduce exposure to COVID-19. The Plan denied your request. The Plan says that you have been
charged the correct cost sharing amount. The Plan also says that there is no copayment for telehealth visits
related to COVID-19 testing.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan acknowledges changes to the cost sharing for telehealth services in
2020. However, the plan has not provided any documentation notifying enrollees of limits to when the waiver
of cost sharing would apply.
Therefore, we decided that the Plan has to waive the copayments for physical therapy telehealth visits provided
on October 19, 2020, and October 26, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 26, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an off-campus outpatient hospital setting and should have been billed with POS code 19. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a shaving of skin growth (11300) provided on November 15, 2021, by an out-of-network provider.
You asked the Plan to pay for a shaving of skin growth. You say that you did not need a referral for the services at issue because the dermatologist is an in-network specialist. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.
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. We confirmed via the Plan website that 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 a shaving of skin growth (11300) provided on November 15, 2021, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echo exam of the abdomen (76705) provided on October 
18, 2021. 
 
You asked the Plan to pay for the echo exam of the abdomen. You say that this service was necessary and 
should be paid. The Plan denied your request. The Plan says this service was not billed in accordance with 
Medicare coding regulations. A National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 93976 and 76705. Modifiers are allowed; however, an appropriate modifier was not used 
in this case. 
 
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 the echo exam of the abdomen (76705) provided on October 18, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records do not show that 
you meet the criteria for coverage of the requested PWC. The records show that the PWC is being requested 
solely for use outside of the home. This item is not covered for use outside of the home and is therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 1 power wheelchair (PWC).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Daratumumab and Dexamethasone Sodium Phosphate for the enrollee.
You asked the Plan to pre-approve Daratumumab and Dexamethasone Sodium Phosphate. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested drugs would be deemed a routine cost of the clinical trial.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Daratumumab and Dexamethasone Sodium Phosphate as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Daratumumab and Dexamethasone Sodium Phosphate for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scooter lift.
You asked the Plan to pre-approve a scooter lift. The Plan denied your request. The Plan says this does not meet the definition of durable medical equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a scooter lift.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a titration study to be provided by an OON provider.
You asked the Plan to pre-approve OON services. You say that the enrollee is anxious to complete his study.
The Plan denied your request. The Plan says this service can be provided in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a
titration study to be provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiovascular stress test (93017) 
provided on April 14, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 up to a 
$175 copayment for each Medicare-covered outpatient diagnostic procedure and test in an outpatient facility.  
 
You have been asked to pay a $175 copayment for the Medicare-covered outpatient diagnostic test provided in 
an outpatient facility. 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 cardiovascular stress test (93017) provided 
on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an Embrace2 watch provided on October 21, 2021.
You asked the Plan to pay for an Embrace2 watch. You say that the item at issue is a medical necessity for you. The Plan denied your request. The Plan says the item at issue is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that telephone alert systems are emergency communications systems and do not serve a diagnostic or therapeutic purpose. While an Embrace2 watch may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for an Embrace2 watch provided on October 21, 2021.