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

 
We decided that the Plan does not have to waive the copayments for primary care provider visits provided on 
August 11, 2021, November 1, 2021, and December 1, 2021. 
 
You asked the Plan to waive the copayments for primary care provider visits. You say that you should not have 
these copayments. The Plan denied your request. The Plan says the copayments applied was correct. 
 
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 primary care provider visits. ($5 x 3 visits = $15) 
 
You have been asked to pay a $15 copayment for primary care provider visits. Primary care provider visits fall 
within the In-Network Primary Care Provider Visits 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 primary care provider visits provided on August 11, 2021, November 1, 2021, and December 1, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services provided from May 5, 2021, to 
May 24, 2021. 
 
You asked the Plan to pay for outpatient therapy services. You say that this plan is your only insurance plan. 
The Plan denied your request. The Plan says this claim must be processed through your primary insurer and the 
explanation of benefits from that plan must be forwarded in order to receive payment. The Plan has directed 
you to contact your primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 The Centers for Medicare and Medicaid (CMS) database shows that you had another insurance company as 
your primary insurer on the dates in question. If you feel that this is incorrect, you may need to contact that 
company or CMS to have these records amended. However, at this time the information provided shows that 
the Plan was not your primary insurer from May 1, 2021, to May 31, 2021. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed 
you to have the provider bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for outpatient therapy services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for outpatient therapy services provided from May 5, 2021, to May 
24, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found although further rehabilitation services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing facility. Admission to a SNF for inpatient skilled rehab 
services is 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 14, 2021, billed 
with codes 81455, two units of 81479, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary testing for 
prognostic information. It is necessary for the treating provider to better select a treatment for the enrollee's 
condition. The Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on December 14, 
2021, billed with codes 81455, two units of 81479, and 81301.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is medically reasonable and necessary. Our physician reviewer found that the enrollee has 
stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing 
and/or skilled therapy services on a daily basis. They are medically stable and can receive further rehab 
services at a lower level of care. Although further rehab services would be appropriate to improve function, as 
a practical matter, the intermittent skilled services can be provided at a lower level of care than 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, excision procedures on the external ear, and a 
tangential biopsy of skin provided on February 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, excision procedures on the external ear, and a tangential biopsy of 
skin. You say that the claim was processed incorrectly with the facility national provider identifier (NPI) and 
not the rendering provider as it should. The Plan denied your request. The Plan says the provider is not in-
network and there is no authorization on file. 
 
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 an office visit, excision procedures on the external 
ear, and a tangential biopsy of skin provided on February 16, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary for prostate cancer. 
The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found that the enrollee has 
biopsy proven cancer, and the presence of an enlarged right iliac lymph node is suspicious for regional lymph 
node metastatic disease. Since radiation therapy is planned it is critical to determine if that lymph node is 
metastatic and the best way to do so is to perform a PET/CT specific for prostate (Axumin scan). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan for the enrollee.  
 
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 this is medically necessary. The Plan denied your 
request. The Plan says the criteria for admission to the Acute Inpatient Rehabilitation 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 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 surgical repair of a hip fracture after a fall and was discharged to skilled nursing facility. 
Family brought her back to acute care because they were concerned about care at the skilled nursing facility. 
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 medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five additional home health physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found 
that the enrollee does not have documented ongoing home health physical therapy needs. The enrollee is 
functioning at a level commensurate with a lower level of care, such as a home exercise program, outpatient 
therapy, or layperson supervision. As such, the ongoing services are not reasonable or 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 the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five additional home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services (procedure code 81271) provided to 
the enrollee on February 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says genetic testing procedures submitted with this denied code is unlikely to impact 
therapeutic decision-making in the clinical management of the patient and will be denied automatically as not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT 81271 will be automatically denied as not 
medically necessary.  
 
Medicare does not consider this type of testing to be medically reasonable or necessary at this time. Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic testing services (procedure code 81271) provided to the 
enrollee on February 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) with 
doppler provided on December 15, 2021. 
 
You asked the Plan to waive the copayment for the TTE with doppler. You say that you do not understand why 
your copayment is $175. 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 $175 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay a $175 copayment for the TTE with doppler. The TTE with doppler is an 
ultrasound procedure and 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 a transthoracic echocardiogram 
(TTE) with doppler provided on December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on December 15, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for surgical pathology services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 surgical pathology services provided on December 
15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening COVID-19 testing provided on April 4, 2022. 
 
You asked the Plan to pay for the screening COVID-19 testing. You say that this is a covered service. The Plan 
denied your request. The Plan says you billed with a non-covered diagnosis code. 
 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 test at issue in this appeal, the screening COVID-19 testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes.  The only diagnosis you billed on this claim 
was Z11.59, indicating an encounter for screening for other viral diseases.  You did not bill with a diagnosis 
indicating that this testing was done for any indication other than screening (such as Z03.818, which would 
indicate suspected exposure to COVID-19, or Z20.828 contact with other viral communicable diseases.)  You 
also did not bill with a diagnosis indicating that the patient had any signs or symptoms related to COVID-19.  
Because the only diagnosis code you billed this test with is a screening diagnosis, and because this is not a 
covered test for screening purposes, we find that this test is not coverable as billed. Therefore, we decided that 
the Plan does not have to pay for the screening COVID-19 testing provided on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on November 
17, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be reprocessed for payment. The Plan 
denied your request. The Plan says only a single code should be reported. 
 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided to the enrollee on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
January 26, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that your physician provided medically 
necessary services in good faith. The Plan denied your request. The Plan says services from non-participating 
providers are not covered unless preauthorized. 
 
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 
services at issue. 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 subsequent nursing facility care provided on January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies (K0553) provided November 26, 2021. 
 
You asked the Plan to pay for the diabetic supplies. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this brand of diabetic supplies is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The brand of diabetic testing supplies at issue is not covered by the 
plan. The record does not show a medical exemption. Based on this information, we decided that Medicare 
rules for coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have 
to pay for diabetic supplies (K0553) provided November 26, 2021.