Persius/hicric huggingface dataset:
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 services required by the enrollee 
exceeds the clinical capabilities of lower levels of care. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate care at the current 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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital with respiratory failure related 
to pseudomonas pneumonia/peritonitis. He was treated with mechanical ventilation. He has end stage liver 
disease and was evaluated for liver transplant. He was treated with paracentesis procedures and tracheostomy. 
He is currently undergoing weaning trials. The enrollee still requires acute care services to continue weaning 
trials and short-term monitoring. He does not require any services at the LTACH that are not already available 
at the current setting. Therefore, this request for LTACH services will be considered not medically necessary at 
this time. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after 
July 24, 2020. 
 
You asked the Plan to pre-approve continued SNF coverage. 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 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 continued SNF coverage. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications. The enrollee required supervision to minimal assistance with bed mobility and transfers. The 
enrollee remained toe touch weight bearing to the right lower extremity and was non-ambulatory. The 
documentation does not support that the enrollee required the specialized skills, knowledge, or judgment of a 
skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and 
reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are 
required on a daily basis. As a practical matter, the enrollee did not require the necessary services on an 
inpatient basis, at a SNF level of 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 continued SNF coverage have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) coverage after July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee reports less than 50% relief from the previous injection. 
 
The Plan follows Medicare rules. Medicare rules say that epidural injections are only covered under certain 
medical indications.  
 
 
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 requested services. Our physician 
reviewer found that the enrollee has a diagnosis of chronic low back pain, lumbar spondylosis and lumbar 
radiculopathy. The pain started over 10 years ago, radiating down the right leg to the level of her knees. The 
enrollee also has neck pain that radiates down her arms with numbness in her hands. In January 2020, the 
enrollee underwent a lumbar epidural steroid injection.  The enrollee received 40% relief from the prior 
epidural steroid injection. Epidural Injections, regardless of approach or indication, are considered not 
medically reasonable and necessary if a prior epidural injection procedure provided limited or no relief (i.e., 
less than 50% symptom improvement). Therefore, based upon the submitted documentation, it is not medically 
necessary and reasonable for this enrollee to have a repeat epidural steroid injection. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar epidural injection.
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 is being treated for acute 
chronic respiratory failure secondary to COPD and underline pulmonary fibrosis. You say that the LTACH is 
the most appropriate level of care. The Plan denied your request. The Plan says services could be provided in 
another setting. 
 
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 any services at the LTACH that are not already 
available 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: 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 is too complex for skilled 
nursing care. The Plan denied your request. The Plan says the enrollee does not appear to be ready for an 
alternative level of 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 current acute care hospital with elevated blood pressure, 
cough and diagnosed with sepsis, pneumonia, and acute on chronic renal failure. She required hemodialysis, 
oxygen, IV antibiotics, steroids, Lasix, and Nicaradipine. The course was complicated by low hemoglobin 
warranting blood transfusions. Currently she is requiring BiPAP only at night. She has been improving and 
current needs include physical therapy, antibiotics, and basic nursing care. The enrollee does not require any 
services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH 
services will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  the enrollee needs long-term care for 
continuous bladder irrigation and hypoveric treatment. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate care at the current acute care 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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital after being found unresponsive 
with gross hematuria related to chronic radiation cystitis following treatment for prostate cancer. Recent notes 
state that her urine was clear after monitoring, bladder irrigation, belladonna suppositories, and iron 
supplementation. The enrollee requires bladder irrigation and hyperbaric oxygen treatment. She still requires 
acute care services, but is improving sufficiently, suggesting no likely need for more than 24 days of additional 
acute care services. The enrollee does not require any services at the LTACH that are not already available at 
the current setting. Therefore, this request for LTACH services will be considered not medically necessary. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is too complex for skilled 
nursing care. You say that the enrollee requires extended acute care to fully resolve the complex medical 
issues. 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 the enrollee does not require any services at the LTACH that are not already 
available at the current facility. Our reviewer says that transfer to a lower level of care may be considered and 
appropriate at a later date. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has had custom orthotics in the past 
that worked very well to alleviate pain. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 18, 2020 by an out of 
network (OON) provider. 
 
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 services were rendered by an out-of-network provider without 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on May 18, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenomic screening panel testing provided on July 
18, 2019. 
 
You asked the Plan to pay for genetic testing. You say that this testing can affect clinical decisions. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the enrollee does 
not have documentation of any specific risks that are appropriate for large panel genetic testing. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
There is no documentation in the record of a concern for a specific drug metabolism issue for which this testing 
was ordered. This means it is screening in nature which is not covered by Medicare. Therefore, we decided that 
the Plan does not have to pay for pharmacogenomic screening panel testing provided on July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650)and an electrical stimulation 
device (E0730) provided on March 23, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis and electrical stimulation device. You say that you 
would like reconsideration because the documentation clearly shows medical necessity based on the doctor's 
review of the member. The Plan denied your request. The Plan says reasonableness of the provided durable 
medical equipment has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis 
(L0650)and an electrical stimulation device (E0730) provided on March 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health services provided March 2, 2020 to 
March 4, 2020. 
 
You asked the Plan to pay for the inpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says services could have been provided in a lower level of 
care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient mental health services. Our 
reviewer says that inpatient mental health care was not medically necessary. Our physician reviewer found the 
enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in 
question of March 2, 2020 forward as this patient was not shown to be a danger to herself or others. She was 
not showing any auditory or visual hallucinations and was cooperative and compliant with 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 inpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient mental health services provided March 2, 2020 to March 4, 
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy provided from January 2, 
2020 to February 20, 2020. 
 
You asked the Plan to waive the copayments for physical therapy. You say that you were told these services 
would not cost you anything. The Plan denied your request. The Plan says the copayment you are being 
charged is correct. 
 
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 in-network Medicare-covered physical therapy and speech therapy services.  
 
You have been asked to pay a $40 copayment for each of 14 physical therapy services from January 2, 2020 to 
February 20, 2020, resulting in a total copayment obligation of $560. Physical therapy falls within the 
outpatient rehabilitation services 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 copayments for 
physical therapy provided from January 2, 2020 to February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits received from an opt out provider from 
November 25, 2019 to December 19, 2019. 
 
You asked the Plan to pay for the office visits. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services received are not payable. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the office visits received from an opt out provider from November 25, 2019 to December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80053, 82962, 36415, and 
86850 provided on February 19, 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 rendered 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 code 80053, 82962, 36415, and 86850 is not supported in the medical record. Specifically, 
these services were billed with a primary diagnosis of Z538 (Procedure and treatment not carried out for other 
reasons). According to the ICD-10-CM manual guidelines for Selection of Principal Diagnosis, it notes when 
the original treatment plan is not carried out, sequence as the principal diagnosis the condition, which after 
study occasioned the admission to the hospital, even though treatment may not have been carried out due to 
unforeseen circumstances. Payment is not allowed for this service because it is not appropriate for the diagnosis 
code billed. 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 the laboratory services coded 
80053, 82962, 36415, and 86850 provided on February 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services provided February 3, 2020 to March 
17, 2020. 
 
You asked the Plan to pay for the transportation services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says insufficient documentation has been received to determine if the 
services can be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. No itemized bill or receipt was provided. Based on this information, 
we decided that Medicare rules for coverage of the transportation services have not been met. Therefore, we 
decided that the Plan does not have to pay for transportation services provided February 3, 2020 to March 17, 
2020.