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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 care for a broken hip, broken humerus and broken ribs after a fall. Medical problems are 
stable. There are no identified problems that need inpatient medical management. 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. The medical record 
supports a need for physical and occupational therapy but it does not support a need for an intensive 
rehabilitation therapy program. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on July 27, 2020. 
 
You asked the Plan to pay for the x-ray services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 x-ray services provided on July 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you have not completed your course in the hospital and your vital signs 
are not stable without significant critical care intervention. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay from May 22, 2020 to 
June 12, 2020. 
 
You asked the Plan to pay for the SNF stay. You say that the enrollee needed SNF care. 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 above 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 pay for the SNF stay. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are not identifiable skilled nursing or 
skilled therapy needs. In addition, the beneficiary did not require skilled nursing or therapy services on a daily 
basis and did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing 
facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF stay have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) stay from May 22, 2020 to June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for diabetic testing supplies (A4235, A4253, A4256 and A4259) provided 
on May 15, 2020. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that you would like reconsideration 
because the supplies are medically necessary. The Plan denied your request. The Plan says that the 
documentation submitted did not include an itemized billing/shipping invoice or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record contains a valid proof of delivery for the supplies provided in this case. Therefore, we decided that 
the Plan has to pay for diabetic testing supplies (A4235, A4253, A4256 and A4259) provided on May 15, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
February 24, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says the services would meet the observation level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services rendered. 
 
You asked the Plan to waive the copayment for these services. You say that you were not told there would be a 
charge. The Plan denied your request. The Plan says the copayment was applied 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 $10 
copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility).  
 
Review of the file shows that you received laboratory services. You have been asked to pay a 
$10 copayment for these services. These services fall within the diagnostic lab services and diagnostic 
procedures and tests (per day, per facility) 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 laboratory services rendered .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant body placement (D6010) and extraction (D7210) 
provided on May 20, 2020. 
 
You asked the Plan to pay for the implant body placement (D6010) and extraction (D7210). You say that this 
was the only dentist available to you. You say that you couldn't live without teeth in your mouth. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
implant body placement (D6010) and extraction (D7210) provided on May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-check brand diabetes supplies (A4253, A4259). 
 
You asked the Plan to pre-approve Accu-check brand diabetes supplies. You say that this should be covered. 
The Plan denied your request. The Plan says only preferred brands of diabetes supplies are covered. 
 
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 as long as the 
enrollee retains access to all medically necessary items (including non-preferred brands). The Plan contract 
says that non-preferred brands of diabetic supplies are 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 Accu-check brand diabetes supplies. 
Our reviewer says that the requested brand of supplies is not medically necessary. Our physician reviewer 
found there is no reason given in the submitted documentation and medical records for why you should or 
could  not use the Plan's preferred brands and why it is medically necessary for you to use the requested brand, 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Accu-check brand diabetes supplies have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Accu-check brand diabetes supplies (A4253, A4259).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for therapeutic radiology simulation provided 
on February 11, 2020. 
 
You asked the Plan to waive the coinsurance for therapeutic radiology simulation. You say that you only had 
an office visit that day and disagree with the charges. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for radiation therapy. 
 
The record shows that therapeutic radiology simulation was provided on February 11, 2020 in preparation for 
radiation treatment. Therefore, you are responsible to pay your share of the cost-sharing charges. The total 
allowed amount is $504.35 and 20% of that is $100.87.   
 
You have been asked to pay the total coinsurance amount of $100.87 for therapeutic radiology simulation. 
Therapeutic radiology simulation 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 coinsurance for therapeutic radiology 
simulation provided on February 11, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Needle electromyography (CPT code 95861) and the 
Continuous intraoperative neurophysiology monitoring services (CPT code 95940) provided. 
 
You asked the Plan to pay for CPT codes 95861 and 95940. You say that the medical records support the 
billing of CPT codes 95861 and 95940. The Plan denied your request. The Plan says the medical records do not 
support the billing of CPT codes 95861 and 95940. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95861 is Needle electromyography; 2 extremities with or 
without related paraspinal areas and the CPT Code Manual definition of code 95940 is Continuous 
intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal 
attendance, each 15 minutes (List separately in addition to code for primary procedure). 
 
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 CPT codes 95861 and 95940. Our reviewer 
says that the medical records do not support the billing of CPT codes 95861 and 95940. Our physician reviewer 
found the medical records do not support the billing of CPT code 95861. There were no nerve conduction 
studies completed on the date of service under review. Pedicle screw stimulation does not meet the definition 
of a NCS (which requires evaluation of surface stimulation and electrodes). Nor was a formal EMG done. 
Rather, EMG needles were placed and were left to "monitor" as a free running modality. This is different than 
performance of a formal EMG in which needles are placed into certain muscles (and removed) to evaluate 
specific function. In as much this code cannot be said to have been submitted properly. 
 
 
 
The medical records also do not support the billing of 22 units of CPT code 95940. First, it was the 
technologist who billed for this code (rather than the monitoring physician). This code is used to reflect the 
work of a physician--not a technologist.    CPT code 95940 is to be used by one supervising professional in the 
operating room monitoring one case. Based on the records provided for review, the supervising professional 
(physician) was not in the OR monitoring, but was connected remotely (as evidenced by the "chat log"). For 
both of these reasons the use of CPT code 95940 is not supported by the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT codes 95861 and 95940 have not been met. Therefore, we decided that the 
Plan does not have to pay for the Needle electromyography (CPT code 95861) and the Continuous 
intraoperative neurophysiology monitoring services (CPT code 95940) provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion device for the enrollee.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says you needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records provided 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 may require skilled physical therapy and occupational therapy but based on the 
medical records provided you do not require treatment in an intensive rehabilitation therapy program. 
 
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 pay for the Request for Anticipated Payment (RAP) for home health 
care services for episode of care beginning June 19, 2019. 
 
You asked the Plan to pay for the RAP for this episode. You say that the claim that was recouped was for a 
RAP that would normally be submitted to Medicare for home health services provided. This was billed 
correctly, and the payment should be returned. The Plan denied your request. The Plan says payment made on a 
RAP is canceled if a final claim for the episode of care is not submitted within a specific time frame. No final 
claim was submitted for this episode of care. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for a RAP is the first portion of 
payment for a home health episode of care and a final claim provides the remainder of payment. Payment for a 
RAP will be canceled if a claim is not received within 60-days of payment or 60-days after the end date of the 
episode.  
 
In this case, the Plan indicates that no final claim was submitted for this episode of care. As such, cancellation 
of payment made on the RAP is correct. Therefore, we decided that the Plan does not have to pay for the 
Request for Anticipated Payment (RAP) for home health care services for episode of care beginning June 19, 
2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the outpatient diagnostic imaging rendered 
on January 22, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you shouldn't have to pay the 
charges. The Plan denied your request. The Plan says the charges were applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $100 yearly deductible for your covered medical services and a $250 
copayment for in-network advanced imaging services at an outpatient hospital. 
 
Review of the file shows that you received outpatient diagnostic imaging services on January 22, 2020. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $100 yearly deductible for 
your covered medical services. This cost sharing is a contractual obligation that had not been met at the time 
these services were received on January 22, 2020. The Plan applied $10.46 towards the deductible for these 
services. At this time, your yearly deductible was met. 
 
Given that the $10.46 deductible charge did not cover the entire cost of the services, you have also been asked 
to pay a copayment. The contract with the Plan states that there is a $250 copayment for in-network advanced 
imaging services at an outpatient hospital. However, the remaining amount after the deductible charge was 
$178.67. Given that the remaining amount was less than the $250 copayment, you have been asked to pay 
$178.67 for these services. 
 
The total amount you have been asked to pay for these services is $189.13. This cost sharing is a contractual 
obligation that you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not 
have to waive the cost sharing for the outpatient diagnostic imaging rendered on January 22, 2020.