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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs daily physician 
monitoring and skilled nursing care at or greater than 6.5 hours a day. You say that the care is complex 
requiring admission to long term acute care. The Plan denied your request. The Plan says care can be provided 
in the current inpatient 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 that the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. 
 
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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on January 23, 
2020 to January 28, 2020 and February 6, 2020 to February 21, 2020 by the provider. 
 
You asked the Plan to pay for SNF care. You say that the services were necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not require skilled services 
January 23, 2020 to January 28, 2020 or February 6, 2020 to February 21, 2020. During the first time frame, 
the enrollee did not have documented skilled nursing or skilled therapy needs. During the second time frame, 
the enrollee was enrolled in Hospice for four days and dead the remaining eleven days. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided on January 23, 2020 to January 28, 2020 and February 6, 
2020 to February 21, 2020 by the provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency medicine services (CPT 99284) provided to the 
enrollee on March 25, 2020. 
 
You asked the Plan to pay for the servcies. You say that this should be paid for. The Plan denied your request. 
The Plan says supporting documentation for CPT 99284 was not included in the submitted documentation. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function. 
 
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 servcies. Our reviewer says that the 
services a Our physician reviewer found another provider from the same group practice in the same specialty 
billed CPT 99284 on same date of service. 
 
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 servcies have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency medicine services (CPT 99284) provided to the enrollee on March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on May 23, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on May 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 18, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
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 billed CPT codes are not supported in the medical record. Specifically, the services were billed 
as if the specimen was collected by blood sampling. However, the records show that the specimen was 
collected by urine sample. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on July 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 7, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to 
be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on 
November 7, 2019. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you should not have a 
copayment because you haven't had one in the past. The Plan denied your request. The Plan says you have been 
charged a copayment correctly for a facility outpatient surgery procedure. 
 
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 $300 
copayment for Outpatient Surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $275.82 copayment, less than your required copayment, for the outpatient 
surgery. The outpatient surgery falls within the Outpatient Surgery, including services provided at hospital 
outpatient facilities 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 outpatient 
surgery provided on November 7, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that the SNF services are medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for a SNF admission. 
 
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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found that the enrollee has stabilized 
medically and is ready for discharge from the hospital. He 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. The enrollee does 
not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is 
medically stable without any acute exacerbations of chronic medical problems. His physical function is at or 
near his baseline and he can receive services at a lower level of care. Admission to a SNF for inpatient skilled 
rehab services is 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. You say that you could decline without skilled care. The 
Plan denied your request. The Plan says you do not have skilled medical needs, and do not require daily skilled 
therapy. 
 
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. 
 
Continued SNF services beyond August 22, 2020, were requested. 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 continued services. Our physician reviewer found that from a nursing 
perspective, you received oral medications, stable vital signs, clear lungs, and uncomplicated wound care. 
There are no identifiable skilled nursing service needs. Regarding rehab services, you are at minimal to 
dependent assist with bed mobility and transfers. You require varying assist with activities of daily living. 
There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services 
on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a 
SNF 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 10, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. The records provided do not contain 
documentation of the ordering physician's intent that the tests be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on February 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy guidelines were not followed. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the review has 
determined that the plan requires a trial of the plan's preferred drugs before they will approve the requested 
drug. In this case the patient has not tried and failed the required drugs. There is no documentation provided 
indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 7, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 CPT codes 80157, 80177, 80201, 80162, 80159, and 80173, are not supported in the medical 
record. Specifically, the services were billed as if the specimen was collected by blood sample. However, the 
records show that the specimen was collected by urine sample. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need to be monitored daily by 
doctors. The Plan denied your request. The Plan says the request does not meet the requirements for approval. 
 
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 you are stable and receiving appropriate care at the current skilled nursing 
facility. Our reviewer says that there are no services available at the LTACH 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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 2, 2020 to March 31, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration because this 
is a per visit claim. The Plan denied your request. The Plan says the claim was billed with type of bill code 323, 
which is not payable. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim has 
been submitted with an inappropriate type of bill code for home health services. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from March 2, 2020 to March 
31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection and application of autologous blood 
concentrate and sinus augmentation with bone or bone substitutes provided on January 14, 2020. 
 
You asked the Plan to pay for the collection and application of autologous blood concentrate and sinus 
augmentation with bone or bone substitutes. You say that the treatments were needed to restore your health and 
gums. You say that the amount is a financial strain. The Plan denied your request. The Plan says the services 
are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
collection and application of autologous blood concentrate and sinus augmentation with bone or bone 
substitutes provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedures provided on May 21, 
2020 and May 29, 2020. 
 
You asked the Plan to pay for the unspecified preventive procedures. You say that you paid $10 for the 
procedure. The Plan denied your request. The Plan says the service is not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive procedures provided on May 21, 2020 and May 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided to the enrollee on March 
4, 2020. 
 
You asked the Plan to pay for outpatient surgery services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the procedure was not pre-certified by the pre-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. 
 
While the enrollee can use out of network providers, providers are responsible for checking their coverage and 
getting pre-authorization. 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 
outpatient surgery services provided to the enrollee on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient surgery services provided on February 13, 
2020. 
 
You asked the Plan to pay for the hospital outpatient surgery services. The Plan denied your request. The Plan 
says non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for hospital outpatient surgery services provided on February 13, 
2020.