Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve ten occupational therapy sessions for the enrollee. 
 
You asked the Plan to pre-approve the sessions. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no evidence that continued input from skilled therapist was necessary to 
restore or maintain function. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 sessions. Our reviewer says that the 
requested sessions are medically reasonable and necessary. Our physician reviewer found the provider 
documents that additional occupational therapy services are indicated to increase range of motion, increase 
upper extremity strength and functional use, and for pain management. It is generally accepted as specific and 
effective therapy for the enrollee's condition. The records demonstrate that the unique skills of a therapist are 
required to safely and effectively provide treatment. 
 
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 sessions have been met. Therefore, we decided that the Plan has to pre-
approve ten occupational therapy sessions for the enrollee.  
 
 
 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2950).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says D2950 is not a covered service, per the 2020 Dental Handbook.
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 pre-approve dental services (D2950).
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the care is not complex enough and does not show it would cause excessive physical hardship for the patient to receive needed care on an outpatient basis or in a skilled nursing facility.
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. 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 urinary tract infection and mental status changes. Medical problems are stable. 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 record does support a need for physical and occupational therapy but there is no need for an intensive rehabilitation 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. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's care could be provided in an alternate setting such as a skilled nursing facility.
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. The patient appears to require additional acute care services for the short term to allow for close monitoring and additional antibiotics, however, less than an additional 25 days of acute care services is likely based on current clinical status. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided January 29, 2020 to February 2, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were charged more than you should have been. The Plan denied your request. The Plan says the correct copayment was applied in this case.
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 $275 per day copayment for Inpatient Hospital Care. You have been asked to pay a $275 per day copayment for 4 days of inpatient hospital care, for a total of $1,100. 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 inpatient hospital care provided January 29, 2020 to February 2, 2020.
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 you had surgery and need rehab. You say that you 
don't want to go to a skilled nursing facility. The Plan denied your request. The Plan says an acute 
rehabilitation facility 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 that based on your current functional status and lack of medical complexity, an IRF 
admission is not medically necessary. Our reviewer says that your rehab needs can be met in a lower intensity 
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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on June 10, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you feel that you should not owe a
second copayment due to the providers mistake. 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 a $275
copayment for each advanced imaging service.
You have been asked to pay a $275 copayment for an MRI. An MRI falls within the outpatient diagnostic tests
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
an MRI provided on June 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for the evaluation and management of an 
established patient (CPT Code 99350) provided to the enrollee on September 3, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. The 
enrollee was seen in their home on September 3, 2019 for a registered nurse (RN) with a licensed vocational 
nurse (LVN) supervision care visit. According to Medicare, home services codes 99341-99350 are paid when 
they are billed to report evaluation and management services provided in a private residence. A home visit 
cannot be billed by a physician unless the physician (or advanced practitioner) was actually present in the 
beneficiary's home. Code 99350 is not supported by the medical records. Specifically, the medical records 
show the submitted services were performed by an RN. The medical record is electronically signed by the RN, 
and the non-participating physician who is billing the services signs the medical record via electronic 
DocuSing. There is no documentation that the physician was present during the home visit. 
 
Therefore, we decided that the Plan does not have to pay for home visit for the evaluation and management of 
an established patient (CPT Code 99350) provided to the enrollee on September 3, 2019.
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 needs close monitoring with daily medical and nursing services. You say that the enrollee still needs acute care for intensive therapy and medical care. The Plan denied your request. The Plan says services can safely be received 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 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 that given the enrollee's current level of function, IRF level of therapies is not required. Our reviewer says that the enrollee's rehab needs can be met in an alternate lower intensity 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on June 17, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you had to return to the 
emergency room due to a defect and feel that you should not have to pay a second copayment. 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 a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls 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 care provided on 
June 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for the evaluation and management of an 
established patient (CPT Code 99350) provided to the enrollee on September 24, 2019. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. The 
enrollee was seen in their home on September 24, 2019 for visit #4 a licensed vocational nurse (LVN) care 
visit. According to Medicare, home services codes 99341-99350 are paid when they are billed to report 
evaluation and management services provided in a private residence. A home visit cannot be billed by a 
physician unless the physician (or advanced practitioner) was actually present in the beneficiary's home. Code 
99350 is not supported by the medical records. Specifically, the medical records show the submitted services 
were performed by an LVN. Appeal submission states the services were rendered by a nurse practitioner (NP), 
however, medical records document the LVN. The medical record is electronically signed by the LVN, and the 
non-participating physician who is billing the services signs the medical record via electronic DocuSign. 
Therefore, we decided that the Plan does not have to pay for home visit for the evaluation and management of 
an established patient (CPT Code 99350) provided to the enrollee on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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
physician's services. 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 physician's services provided on June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound services (CPT 76882) provided to the enrollee on
April 20, 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 per a review of the submitted documentation, CPT 76882 is not supported as being performed on
4/20/20, and therefore it is not supported as being performed as a distinct service.
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 76882 is "Ultrasound, limited, joint or other nonvascular
extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue
structure[s], or soft-tissue mass[es]), real-time with image documentation."
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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the CPT
93970 was appropriated coded and reimbursed as a bilateral lower extremity venous ultrasound. There was a
second study done on 4/20/20 interpreted by a different radiologist. The dictated study listed under technique a
limited lower extremity arterial duplex study, but the actual study did not include a description of arterial flow.
Rather the indication for the exam according to the technique was a limited soft tissue ultrasound for possible
abscess. As such, the study should not have been coded as 726882-26 but rather a lower extremity, limited with
a code of 726881.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for ultrasound services (CPT 76882) provided to the enrollee on April 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for the evaluation and management of an 
established patient (CPT Code 99350) provided to the enrollee on September 19, 2019. 
 
You asked the Plan to pay for the services. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. The 
enrollee was seen in their home on September 19, 2019 for visit #3 of registered nurse (RN) care visit. 
According to Medicare, home services codes 99341-99350 are paid when they are billed to report evaluation 
and management services provided in a private residence. A home visit cannot be billed by a physician unless 
the physician (or advanced practitioner) was actually present in the beneficiary's home. Code 99350 is not 
supported by the medical records. Specifically, the medical records show the submitted services were 
performed by an RN. Appeal submission states the services were rendered by a nurse practitioner, however, 
medical records document a RN. The medical record is electronically signed by the RN, and the non-
participating physician who is billing the services signs the medical record via electronic DocuSign. There is no 
documentation that the physician was present during the home visit. Therefore, we decided that the Plan does 
not have to pay for home visit for the evaluation and management of an established patient (CPT Code 99350) 
provided to the enrollee on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit injection services. 
 
You asked the Plan to pre-approve the Procrit injection services. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy. The Plan 
says that there is no documentation supporting the medical necessity for a step therapy exception. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Procrit injection services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
not tried and failed the required drug (Retacrit). The Plan's required drug (Retacrit) would not likely be less 
effective and/or likely have adverse effects for the enrollee than the requested drug Procrit. 
 
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 Procrit injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Procrit injection services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic mammography provided on May 5, 2020. 
 
You asked the Plan to pay for the diagnostic mammography. The Plan denied your request. The Plan says you 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 
diagnostic mammography. 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 diagnostic mammography provided on May 5, 
2020.