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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from May 
16, 2020, to May 31, 2020. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the provider has 
reported skilled services with the incorrect PDPM Health Insurance Prospective Payment System (HIPPS) 
score.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate HIPPS rate code. The medical record must support the 
billed codes.  
 
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 the SNF services. Our reviewer says that the 
criteria for coverage have not been met. Our reviewer found that it appears that the enrollee was placed on 
isolation, not because of an actual infection, but per SNF protocol to assure that newly admitted patients did not 
have unidentified COVID. A nursing function score of 0-14 is not supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services rendered from May 16, 2020, to May 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on January 26, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that this service is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bathtub wall rails. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs assistance with the bathtub. 
The Plan denied your request. The Plan says the services are not covered. 
 
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 bathtub wall rails.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening study for abdominal aortic aneurysm (AAA) 
(76706) provided on January 20, 2022. 
 
You asked the Plan to pay for the screening study for AAA. You say that this service performed was 
appropriate with the diagnosis code. The Plan denied your request. The Plan says this claim was billed with 
diagnosis code Z13.6 (Encounter for screening for cardiovascular disorders) and I70.0 (Atherosclerosis of 
aorta) which does not indicate the criteria for coverage. The Plan also says the documentation received does not 
indicate that the enrollee received the screening study for a family history of abdominal aortic aneurysm, a man 
aged 65 to 75 who has smoked at least 100 cigarettes in his lifetime, or other risk factors recommended by the 
United States Preventive Services Task Force. 
 
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. Medicare rules also say that payment may be made 
for a one-time ultrasound screening for AAA for beneficiaries who meet the criteria listed in the Medicare rules 
section of this letter. 
 
The test at issue in this appeal, the screening study for AAA, was requested solely for screening purposes. 
Specifically, this AAA screening was provided for cardiovascular disorders. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the screening study 
for abdominal aortic aneurysm (AAA) (76706) provided on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the Good Measures phone application/subscription (A9270). 
 
You asked the Plan to pre-approve the Good Measures phone application/subscription. You say that you are a 
diabetic, morbidly obese, have used many different weight loss plans, and have failed to lose enough weight 
and keep the weight off as well as control your diabetes. You also say that the Good Measure application 
allows you to plan meals and track the nutrients in the food you consume. The Plan denied your request. The 
Plan says that this application would not be covered under any benefit offered as there is a lack of information 
about the application, and it cannot show that it follows a similar structure of other covered weight 
management applications. 
 
The Plan must follow Medicare rules. Medicare rules say that the health plan must provide you with a clear and 
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under 
your plan contract including applicable conditions and limitations and any other conditions associated with the 
use or receipt of the benefits. 
 
We looked at the file and Medicare rules. We found that the Good Measures application/subscription shows to 
be a program designed to help with weight loss. The application does not include pre-packed meals/foods, 
books, videos, scales, or other items or supplies. The 2023 Evidence of Coverage clearly states that the Plan 
will reimburse members up to a maximum of $150 per calendar year towards program fees for weight loss 
programs. There is no provided documentation showing this benefit has already been exhausted. The Plan 
contract also does not list specific programs that are covered, but rather gives certain examples of covered 
weight loss programs. Based on this information, we decided that Medicare rules for coverage of the Good 
Measures phone application/subscription have been met. Therefore, we decided that the Plan has to pre-
approve the Good Measures phone application/subscription (A9270).  
 
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 related to end-stage renal disease 
(ESRD) provided on December 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to end-stage renal disease (ESRD) provided on 
December 16, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on July 16, 2021, to August 11, 
2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
service was billed correctly and should be paid at the DRG originally billed. The Plan denied your request. The 
Plan says that the billed secondary diagnosis of G93.41 (Metabolic encephalopathy) is not supported by the 
medical record. Removal of this diagnoses resulted in a lower DRG being paid. 
 
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 provided with secondary diagnosis of G93.41 (Metabolic 
encephalopathy). 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 the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the billed secondary diagnosis of G93.41 
(Metabolic encephalopathy) is supported by the medical record. Our physician reviewer found the enrollee 
presented with hypercalcemia, increasing confusion and weight loss.  It appears that the enrollee may have had 
some dementia, which had become more prevalent since the death of her husband.  But it also appears that the 
enrollee had multiple sources of additional acute confusion (hypercalcemia, hyperammonemia, malnutrition, 
infections).  As such, the billing of G93.41 is supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on July 16, 2021, to August 11, 2021, at the Diagnosis Related Group (DRG) 
originally billed.  
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 10, 
2023. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were misinformed of the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $75 copayment for the ultrasound. This item/service falls within the in-network 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the ultrasound provided on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the OON acupuncture services. You say that you tried to make 
appointments with two providers that you were told were in-network. You say that one of these providers said 
that they were not accepting new patients and the other said that they are not participating with the Plan.  The 
Plan denied your request. The Plan says they have confirmed that there is a network acupuncture provider who 
is accepting new patients.  
 
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 
acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 25, 2022. 
 
You asked the Plan to pay for the medical services. You say that the patient provided incorrect insurance 
information, which is why there was a delay in filing this claim. The Plan denied your request. The Plan says 
you did not timely file this claim with the Plan. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for the 
medical services was not filed until February 18, 2023. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay 
for medical services provided on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on January 
17, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to ESRD provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on 
December 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to ESRD provided on December 6, 2022.
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 enrollee currently meets IRF admission criteria 
under Medicare guidelines. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an IRF. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has a history of stroke and vertigo and is living at home with weakness and falls. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. While the medical records support 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 the 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on October 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had a 
seizure while you were at the doctor's office, and the called 911. You also say that you would like the Plan to 
either pay the ambulance bill, or come to an agreement with the doctor's office to pay the ambulance bill 
because of the 911 policy they have in place. The Plan denied your request. The Plan says this claim processed 
correctly according to the contract and Medicare guidelines and there was no plan error. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on November 
10, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing is medically necessary and should be 
covered.  The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. The Plan also says that you billed with an incorrect Place of Service on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. In addition, Medicare rules say that, for lab services, the POS code must reflect the location in 
which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. This 
claim was billed with the laboratory POS code. The records do not support that the sample was taken in a 
laboratory setting. 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 provided on 
October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets criteria for admission. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
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. 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. 
 
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.