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

We decided that the Plan has to pre-approveinpatient psychiatric hospital services.You asked the Plan to pre-approveinpatient psychiatric hospital services. You say that these services are medically necessary.The Plan denied your request. The Plan says that that you can be treated in a lower level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are medically reasonable and necessary in this case. You appear to require inpatient mental health treatment as although you are not a danger to yourself or others as you were responding to internal stimuli. It appears that active treatment is taking place. It appears that the services were reasonably expected to improve your condition or for the purpose of diagnosis. There is no individualized treatment plan however the entire record is not present. It appears that the records were supervised and evaluated by a physician. Based upon review the records provided you do meet the criteria for acute inpatient mental health treatment as although you were not shown to be a danger to yourself or others and were without agitation or aggression. You do have perceptual disturbance including auditory hallucinations. Our physician reviewer found that your condition meets criteria for coverage of inpatient psychiatric hospital services. We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met.Therefore, we decided that the Plan has to pre-approveinpatient psychiatric hospital services.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographic angiography services provided on 
July 7, 2020. 
 
You asked the Plan to pay for the computed tomographic angiography services. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes that support 
medical necessity of Computed Tomographic Angiography.   
 
We looked at the file and Medicare rules. Diagnoses A41.9 (Sepsis, unspecified organism), R07.9 (Chest pain, 
unspecified), and R41.82 (Altered mental state, unspecified) are not listed as covered diagnoses codes for the 
services provided. Based on this information, we decided that Medicare rules for coverage of the computed 
tomographic angiography services have not been met. Therefore, we decided that the Plan does not have to pay 
for the computed tomographic angiography services provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration 
because the member's procedure and recovery allowed them to be outpatient rather than inpatient. The Plan 
denied your request. The Plan says inpatient only procedures are not separately payable per Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no payment under the OPPS for services 
that CMS designates to be ?inpatient-only? services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Specifically, the record and claim indicate these 
services were for outpatient hospital care. CPT codes 63081 and 22846 have a status indicator of C, meaning 
they are inpatient only codes. There is no payment under the OPPS for these services. Therefore, we decided 
that the Plan does not have to pay for outpatient hospital services provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 19, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 19, 
2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a closed head injury secondary to a fall after seizure. Medical problems are stable. There are no 
identified problems that need inpatient medical management. There are no complex nursing or rehabilitation 
needs. The patient 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 this patient 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic prostate test provided on June 22, 2020. 
 
You asked the Plan to pay for the genetic prostate test. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The genetic prostate test at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic prostate test provided on June 22, 2020.
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 the enrollee will be best treated under the 
oversight of a medical doctor and acute clinical interventions. The Plan denied your request. The Plan says the 
enrollee does not have therapy needs, or need to see a medical provider every day. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital for hypoxia, septic shock, and 
pneumonia. He was treated with antibiotics and oxygen. He is recently noted to have been improving, but 
requires additional antibiotics, basic sacral wound care, and tube feeding. The enrollee appears to be improving 
and responding to treatment. It is unexpected for the enrollee to require more than an additional 25 days of 
acute care services. The enrollee does not require services at the LTACH that are not already available at the 
current facility. Therefore, this request for LTACH services will be considered 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 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.
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 the enrollee requires aggressive 
management to maximize her progress. The Plan denied your request. The Plan says the enrollee does not 
require special long term acute care for more than 25 days. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital for acute respiratory failure and 
subarachnoid hemorrhage related to a ruptured aneurysm. She was treated with mechanical ventilation, an 
emergent external ventricular drain, and coiling. Tracheostomy was performed. She has weaned to be able to 
tolerate trach collar for part of the time. She is still using a nasogastric tube for feeds. The enrollee appears to 
be improving and tolerating weaning, but is not yet stable for discharge due to no permanent feeding tube or 
successful oral intake yet, as well as additional ventilation weaning needs. However, it is unexpected for the 
enrollee to require more than an additional 25 days of acute care services. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH 
services will be considered 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 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.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomographic angiography (CTA) head, with and 
without contrast material (70496). 
 
You asked the Plan to pre-approve the CTA of head. You say that the enrollee is a high risk for stoke and has 
been getting this annually. The Plan denied your request. The Plan says that CTA of head is not reasonable and 
necessary under Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CTA of head. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has a history of carotid stenosis s/p left carotid endarterectomy with stent 
placement in 2012. Repeat CTA of head and neck 8/2018 revealed occlusion of the left common carotid stent. 
Separately, duplex ultrasound from 9/23/19 revealed 50-69% stenosis of the right internal carotid artery. The 
enrollee had been previously approved for the neck CTA, but not for the head CTA. The head CTA is also 
necessary to evaluate the cerebral blood flow and areas of potential ischemia, low blood flow related to areas of 
occlusion in the neck. 
 
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 CTA of head have been met. Therefore, we decided that the Plan has to pre-
approve computed tomographic angiography (CTA) head, with and without contrast material (70496).  
 
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 Guardant360' molecular pathology genomic profiling 
provided to the enrollee on June 24, 2020. 
 
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 Medicare requires use of CPT 81479 to report a Guardant360' molecular pathology genomic 
profiling for lung cancer. 
 
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 Guardant360' molecular pathology genomic profiling provided to the enrollee on June 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says it is not medically necessary for transfer of care to an LTACH, as 
appropriate care is being received in the acute care hospital. 
 
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 records show that you are improving. Although you require short-term acute care 
for additional stabilization and treatment, this should take less than 25 days, and could safely be completed at 
the current facility. You do not require services at the LTACH that are not already available at the current 
setting. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a 
lower level of care may be considered when treatment has completed and your needs are less complex. 
 
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 admission to a long-term acute care hospital (LTACH).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 12, 
2020. 
 
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 blood specimen collection is by venipuncture, however, the lab requisition states a urine 
specimen was collected. 
 
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 the denied codes is: 
 
CPT 80157: 
 
Carbamazepine; free testing 
 
CPT 80159: 
 
Clozapine testing 
 
CPT 80173: 
 
Haloperidol testing 
 
CPT 80177: 
 
 
 
Levetiracetam testing 
 
CPT 80201: 
 
Topiramate testing 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
documentation submitted was reviewed, and does not meet the criteria. The laboratory report documents urine 
was collected, therefore these codes cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. 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 drug testing services provided to the enrollee on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital hearing aids (V5258) provided on June 16, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the hearing aids were not purchased from the 
hearing aid vendor indicated in the contract. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a designated hearing aid vendor.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids were not purchased from the Plan 
designated vendor indicated in the contract. Therefore, we decided that the Plan does not have to pay for the 
digital hearing aids (V5258) provided on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97810, 97811) provided May 27, 2020 
to June 20, 2020. 
 
You asked the Plan to pay for the acupuncture services. You say that the services should be covered. The Plan 
denied your request. The Plan says they have reimbursed the $100 allowed under the plan contract towards the 
services and the remaining balance is the enrollee's responsibility. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record shows that the plan reimbursed the 
allowable $100 towards acupuncture services provided May 27. The benefit was exhausted. Therefore, we 
decided that the Plan does not have to pay for acupuncture services (97810, 97811) provided May 27, 2020 to 
June 20, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services received in an emergency room 
setting provided on June 12, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received services in an outpatient emergency room department on the 
date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract 
with the Plan. 
 
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 $120 
copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services 
provided in an emergency room on June 12, 2020. You have been asked to pay a $120 copayment for the 
emergency room services. The emergency room services 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 the services received in an emergency room setting provided 
on June 12, 2020.