Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator type walker with wheels and brake and a seat 
attachment. 
 
You asked the Plan to pre-approve a rollator type walker with wheels and brake and a seat attachment. You say 
that you can't take one step without holding onto something. The Plan denied your request. The Plan says that 
this is not medically necessary and covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a standard rolling walker. A standard rolling walker serves the same purpose as a 
rollator type walker with wheels and brake and a seat attachment. Therefore, we decided that the Plan does not 
have to pre-approve a rollator type walker with wheels and brake and a seat attachment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. 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 an office visit provided on March 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an 
in-network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that he would like additional time in a SNF to 
continue to work on strength, endurance, functional tasks, and mobility to reach his highest level for a safe 
return home. The Plan denied your request. The Plan says authorization denied because the SNF care is not medically necessary, and the enrollee's needs are currently receiving adequate and necessary intensive 
rehabilitation in the inpatient rehabilitation facility. 
 
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 the SNF care. Our reviewer says that 
the SNF care is not medically necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs that require skilled nursing services, including the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. There are identifiable skilled therapy service needs that require skilled therapy services, including 
the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment. You do not require skilled nursing or therapy services on a daily 
basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility setting. Records do not show that continued services in the acute inpatient 
rehabilitation facility are not appropriate in this case. You are tolerating and benefitting from treatment in the 
acute inpatient rehabilitation facility and the health plan has not stated that continued care in the acute inpatient 
rehabilitation facility will not be covered. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by an in-network facility.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services (ER) on 
December 27, 2021. 
 
You asked the Plan to waive the copayment for emergency room services (ER). You say that this was an 
inpatient stay, thus the copay should be waived. The Plan denied your request. The Plan says the cost-sharing 
you are being charged is 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 $100 
copayment for Medicare-covered emergency and post-stabilization care.  Emergency care refers to services that 
are: furnished by a provider qualified to furnish emergency services and needed to evaluate or stabilize an 
emergency medical condition. 
 
 
 
 
 You have been asked to pay a $100 copayment for emergency room services (ER). Emergency room services 
(ER) fall within the Emergency 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 
emergency room services (ER) on December 27, 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 the acute inpatient rehabilitation hospital 
appears to be providing for all of your present inpatient care needs and you are receiving an appropriate level of 
care in the present setting. Continued care in the acute inpatient rehabilitation hospital appears to be appropriate 
until your confusion and agitation improve, and you are stable to transfer to 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 17, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. 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 March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 it was 
determined these services can be received 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 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 provided on February 21, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 16, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the lab tests are included in the 
dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on December 16, 2021.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the medical criteria for an IRF admission has 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 does not have brain injury or limb impairment requiring 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for urostomy supplies provided from April 5, 
2022, to April 14, 2022. 
 
You asked the Plan to waive the coinsurance for urostomy supplies. You say that you have never been charged 
this much in the past and dont know why you are now. The Plan denied your request. The Plan says the 
coinsurance applied is 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 20% 
coinsurance for Medicare-covered medical supplies.  
 
You have been asked to pay $52.40 which is 20% of the allowed amount for ostomy supplies. The allowed 
amount is $261.60 (20% x $261.60= $52.40). Urostomy supplies fall within the Prosthetic Devices and Related 
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 coinsurance for urostomy supplies 
provided from April 5, 2022, to April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 24, 2020 billed 
with codes 0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81401, 
81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 
November 24, 2020 billed with codes 0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 
81291, 81328, 81355, 81401, 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on January 18, 2022. 
 
You asked the Plan to pay for the services provided. You say that the number of units rendered were medically 
necessary. The Plan denied your request. The Plan says there is no documentation of the testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
In this case, the MUE for CPT code 88342 is 4. You billed 5units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the pathology services provided on January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from December 20, 2020, 
through December 23, 2020, at DRG 193. 
 
You asked the Plan to pay for inpatient services at DRG 193. You say that acute respiratory failure with 
hypoxia is supported by documentation and is a valid assigned diagnosis. You say that DRG 193 should be 
reconsidered. The Plan denied your request. The Plan says secondary diagnosis code J96.01 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code J96.01, defined as acute respiratory 
failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient services at DRG 
193. Our reviewer says that the documentation does not support secondary diagnosis code J96.01. Our 
physician reviewer found that the provider stated acute chronic obstructive pulmonary disease exacerbation as 
the assessment. History and physical notes also noted non labored respiratory effort at the time of physical 
assessment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from December 20, 2020, through December 23, 2020, at DRG 193.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient care provided from August 10, 2021, to August 17, 2021. 
 
You asked the Plan to pay for inpatient care. You say that you have provided medical records to support the 
services billed. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the Plan's denial notices in the case record indicate that the Plan 
had medical records available for its review. These medical records were not forwarded to the independent 
reviewer. It is the Plan's responsibility to substantiate its denial. In this case, the denial has not been 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for inpatient care 
provided from August 10, 2021, to August 17, 2021.  
 
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 coded 80053 and 85025 provided on 
February 4, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT codes 80053 and 85025 are not supported in the medical record. Specifically, these services 
must be billed with the QW modifier. This means the claim is not payable as billed. Based on this information, 
we decided that Medicare rules for coverage of the laboratory services have not been met. 
 
  
 Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80053 and 85025 
provided on February 4, 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 this is the best treatment for him to get strong 
enough so that he can be more independent. The Plan denied your request. The Plan says that the services you 
need can be provided safely in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for non-operative management of a 
humerus fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do 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 you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: 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 that the LTACH is the most appropriate 
level of care. The Plan denied your request. The Plan says authorization denied because the LTACH is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
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 the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The medical record does not indicate that the enrollee 
requires services that he is not currently receiving but that would be available at the LTACH 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 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.