Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (S9131) provided on April 9, 2020. 
 
You asked the Plan to pay for physical therapy services. You say that these services should be processed in-
network. The Plan denied your request. The Plan says this provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The record does not show that the provider of these services is 
enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of 
physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy services (S9131) provided on April 9, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda (pembrolizumab). 
 
You asked the Plan to pre-approve Keytruda, (J9271). You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says that the records sent do not meet the requirements for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda, (J9271). Our reviewer says 
that the drug is medically necessary. Our physician reviewer found the use of this drug is not listed as not 
indicated, not supported or not recommended in any of the compendia. The documentation supports that the 
requested drug is medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, (J9271) have been met. Therefore, we decided that the Plan has to 
pre-approve Keytruda (pembrolizumab).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital observation stay you had on 
October 29, 2019. 
 
You asked the Plan to waive the copayment for the hospital observation stay. You say that you went to the ER 
and were placed in an observation room.  You say that your symptoms resolved, so you checked yourself out.  
Because of this, you say you should only have to pay your emergency room copayment. The Plan denied your 
request. The Plan says you were charged this copayment 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 $210 
copayment for outpatient hospital observation stays at a hospital facility.  
 
You have been asked to pay a $210 copayment for the hospital observation stay. This copayment applies 
regardless of how long you are on observation and what services you receive while there. 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 hospital observation stay you had on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on May 19, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.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 test at issue in this appeal, a cardiovascular risk panel, 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 forthe laboratory services rendered on May 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care to return to a prior level 
of function. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 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 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 22, 2020. 
 
You asked the Plan to pay for the physician's 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 
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 July 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the leg (73700) performed on 
June 11, 2020. 
 
You asked the Plan to waive the copayment for a CT scan of the leg. You say that this service should not be a 
separate charge. The Plan denied your request. The Plan says the correct copayment was 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 $150 
copayment for each Medicare-covered advanced radiology service.  
 
You have been asked to pay a $125.84 copayment for a CT scan of the leg. A CT scan of the leg falls within 
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you 
have been asked to pay less than or equal to 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 CT scan of the leg (73700) performed on June 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on March 15, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 
service 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 a domiciliary, rest home visit provided on March 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe arthrocentesis, aspiration and/or injection (20611) provided February 26, 2020.You asked the Plan to pay forthe arthrocentesis. You say that the records show ultrasound guidance was used due to obesity around the knee or difficulty aspirating synovial fluid and uncertainty of exact location of the needle tip.The Plan denied your request. The Plan says the records do not support service billed. There is insufficient documentation to corroborate the services to confirm Medicare coverage has 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.In this case, the CPT Code Manual definition of code 20611 is arthrocentesis, aspiration and/or injection.We find that CPT code 20611 is not supported in the medical record. Specifically, the documentation submitted did not contain documentation of permanently recorded images to support the billed charge. The plan made Multiple attempts to contact the provider for additional information without success. Based on this information, we decided that Medicare rules for coverage of the arthrocentesis have not been met.Therefore, we decided that the Plan does not have to pay forthe arthrocentesis, aspiration and/or injection (20611) provided February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for level IV surgical pathology, gross and microscopic 
examination (88305) provided January 6, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you already submitted this online. Medical 
note for date of service was not printing properly. Complete note is enclosed. The Plan denied your request. 
The Plan says the records do not support the service billed. The enrollee had 2 excisions and 1 complex repair. 
There is insufficient documentation to corroborate the services to confirm that Medicare coverage has 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. 
 
In this case, the CPT Code Manual definition of code 88305 (3 units) is level IV surgical pathology, gross and 
microscopic examination. 
 
We find that CPT code 88305 (3 units) is not supported in the medical record. Specifically, the documentation 
submitted did not support the units billed. The plan had made multiple attempts to obtain the additional records 
from the provider without success. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for level IV 
surgical pathology, gross and microscopic examination (88305) provided January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on January 16, 
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 the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that GeneSight? testing may only be ordered by licensed 
psychiatrists or neuropsychiatrists. 
 
We looked at the file and Medicare rules. The file shows that the ordering provider is not a licensed psychiatrist 
or neuropsychiatrist. 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 GeneSight Psychotropic 
Assay rendered on January 16, 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 needs 6 weeks of IV 
antibiotics. The Plan denied your request. The Plan says the enrollee's care is not complex, and does not require 
specialized care. 
 
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 acute hospital with bacterial endocarditis. He developed 
blood clots in his legs and bedsores on his heels that will require dressing changes. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where he is currently receiving care. The requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to 
be furnished safely and effectively only on an inpatient basis. 
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is an extreme fall risk. The Plan denied 
your request. The Plan says the enrollee's care is not complex, and she does not need a team of providers. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for surgical repair of hip fracture after a fall. Her medical 
problems are stable. The complexity of the enrollees nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record 
supports a need for physical and occupational therapy, but it does not support a need for 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you would like the 
copayments to be fully covered by the Plan. The Plan denied your request. The Plan says the copayment 
applied correctly 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 $40 
copayment for physical therapy visit.  
 
You have been asked to pay a $40 copayment for physical therapy visits. These services fall within the physical 
therapy visit 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 physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had respiratory arrest and needs more 
extensive care at the IRF. The Plan denied your request. The Plan says the denial of authorization for IRF 
service is correct. 
 
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 respiratory arrest and medical problems are stable. While the enrollee may need treatment by 
multiple therapies, including either physical therapy or occupational therapy, the record 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PVA (CPT Code 22513 X1). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 service. Our physician reviewer 
found the criteria for kyphoplasty are not met. There is no documentation that the fracture is less than six (6) 
weeks old. Also, recent literature shows that kyphoplasty is not effective for the treatment of compression 
fractures. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PVA (CPT Code 22513 X1).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a short term acute care hospital is 
inadequate to the enrollee's needs. The Plan denied your request. The Plan says rules for LTACH care have not 
been met. 
 
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 that the enrollee appears to be gradually improving and requires only short-term 
acute care services of likely fewer than 25 days, which can be completed at the current facility. Also, tube 
feeding is not stable enough for transfer at this time. The enrollee does not require services at the LTACH that 
are not already available at the current setting. There are no services at the current facility that the enrollee 
requires that are not already available and covered at the current 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.