Persius/hicric huggingface dataset:
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 had 
a prolonged hospitalization for treatment of pericardial and mediastinal hematoma with complications 
including respiratory and renal failure. The patient is now living in skilled nursing facility receiving physical 
therapy services. Medical conditions are stable. There are medical needs requiring inpatient admission. 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. 
While the medical record documents a need for physical and occupational therapy, it does not document a 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. 
  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on April 1, 2020, to April 23, 2020.

You asked the Plan to waive the copayment for a skilled nursing stay. You say that you were stuck there during quarantine and you were not allowed to be discharged. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $0 copayment per day for days 1-20. There is a $160 copayment per day for days 21-62 for skilled nursing facility care. 

You have been asked to pay a $0 copayment per day for days 1-20. There is a $160 copayment per day for days 21-62 for a skilled nursing stay. You are being asked to pay is $2,040 due to reaching your out-of-pocket maximum. A skilled nursing stay falls within the skilled nursing facility 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 a skilled nursing stay provided by a participating provider on April 1, 2020, to April 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network rehabilitation services provided from January 
6, 2020 to January 23, 2020.  
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 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 out of network rehabilitation 
services provided from January 6, 2020 to January 23, 2020.
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 you need to go to rehab as you will not do well in a 
nursing home or at home. The Plan denied your request. The Plan says that you can safely receive the services 
you need 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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for gangrene of the foot and had a 
below the knee amputation. Your medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services billed with codes 82180, 82306, 
84446, 84590, and 84597 provided on July 6, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services 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 laboratory testing 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 
laboratory services billed with codes 82180, 82306, 84446, 84590, and 84597 provided on July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care from December 10, 2020, 
through December 15, 2020. 
 
You asked the Plan to pre-approve acute inpatient hospital 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 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 pre-approve 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 according to the notes, the patient was hemodynamically stable, had no 
acute abnormality on head or other imaging, and labs were essentially stable or normal. The patient was not 
expected to require hospitalization that would cross two (2) 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 pre-approve 
inpatient hospital care from December 10, 2020, through December 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for revascularization (37229) and radiological supervision and 
interpretation (75710) provided on June 2, 2020. 
 
You asked the Plan to pay for revascularization and radiological supervision and interpretation. You say that 
this was billed correctly. 
 The Plan denied your request. The Plan says these codes are not supported. 
 
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 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 revascularization and radiological 
supervision and interpretation. Our reviewer says that the use of these codes is not supported. Our physician 
reviewer found the medical records provided do not include sufficient documentation of validated that a 
revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
atherectomy, includes angioplasty within the same vessel, when performed was performed on June 2, 2020, 
therefore, CPT 37229 cannot be verified.  CPT 75710 has a bundled relationship with code 37225 and cannot 
be paid as billed. This code cannot be paid as a separate line item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization and radiological supervision and interpretation have not been 
met. Therefore, we decided that the Plan does not have to pay for revascularization (37229) and radiological 
supervision and interpretation (75710) provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network acupuncture provided from July 28, 2020, to 
August 9, 2020. 
 
You asked the Plan to pay for out of network services. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 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 out-of-network acupuncture 
provided from July 28, 2020, to August 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder services rendered on February 26, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 20680 and 29823 are not supported. 
 
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 20680 is removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate). The definition of code 29823 is arthroscopy, shoulder, surgical; 
debridement, extensive. 
 
We find that CPT codes 206080 and 29823 are not supported in the medical record. Specifically, there is no 
documentation of removal of a deep implant to support code 20680. There is no documentation of a shoulder 
arthroscopy with extensive debridement to support code 29823. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the shoulder services rendered on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interspinous and/or interlaminar device (CPT Code 
22869). 
 
You asked the Plan to pre-approve the device. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies haven't proven that the use of the product(s) is helpful for treatment of 
the member's health problem. 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 items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the device remains 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 interspinous and/or interlaminar device (CPT Code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ophthalmological eye exam (92014) 
provided on February 5, 2020. 
 
You asked the Plan to waive the coinsurance for an ophthalmological eye exam. You say that this should be 
covered as post-operative care. The Plan denied your request. The Plan says this processed 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 40% 
coinsurance for each out-of-network Medicare-covered vision care visit.  
 
You have been asked to pay a 40% coinsurance of $30.81 for an ophthalmological eye exam. 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 an ophthalmological eye exam (92014) provided on February 5, 
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. 
The Plan says the skills of a licensed therapist or nurse are not needed. 
 
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 the admission. Our reviewer says that daily skilled services are 
not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the 
hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically 
stable and can receive further rehab services at a lower level of care. Although further rehab services would be 
appropriate to improve function, as a practical matter, the daily skilled services can be provided at a lower level of care 
than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve 
admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT codes 81292 and 81295. We decided that the Plan does not have 
to pay for CPT codes 81298, 81317, and 81321.  
 
You asked the Plan to pay for CPT codes 81292 and 81295. You say that these tests should be covered. The 
Plan says that these tests are considered experimental. 
 
We decided that the Plan has to pay for CPT codes 81292 and 81295.  
 
 
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
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 81292 and 81295. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this patient has a history of both a non-medullary thyroid cancer, a breast cancer, and most 
recently a urothelial cancer. Despite a family history listed as having no malignancy these raise the suspicion 
for an inherited propensity to cancer for several different genes. Results could potentially have affected her 
screening and treatment options despite her advanced age. The service was reasonable and 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 CPT codes 81292 and 81295 have been met. Therefore, we decided that the 
Plan has to pay for CPT codes 81292 and 81295.  
 
We also decided that the Plan does not have to pay for CPT codes 81298, 81317, and 81321. 
 
The Plan follows Medicare rules. Medicare rules say that when more than two codes from the Local Coverage 
Article: Billing and Coding: MolDX: Testing of Multiple Genes Group 1 list are submitted for the same 
beneficiary on the same date of service, the claims processing system will reject every code submitted after the 
first two services. 
 
While the services represented by CPT codes 81298, 81317, and 81321 have been determined to be medically 
necessary, they cannot be paid without an appropriate modifier. Therefore, we decided that the Plan does not 
have to pay for CPT codes 81298, 81317, and 81321. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy services. 
 
You asked the Plan to pre-approve occupational therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 occupational therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the enrollee required stand-by assistance with 
mobility during activities of daily living. The enrollee required contact guard assistance with toileting. The 
enrollee has had extensive therapy for this condition and it does not appear that the enrollee requires the unique 
skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely 
and effectively performed only by a therapist, or under the supervision of a therapist. There has been caregiver 
and enrollee education on enrollee's functional condition, safe transfers, positioning and prevention of decline. 
The  specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
 
 
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occupational therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve occupational therapy services.