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 enrollee needs LTACH care. The 
Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's 
medical needs are being met in the current acute 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 all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial inpatient physician visit provided on April 28, 
2022, billed with code 99223. 
 
You asked the Plan to pay for the inpatient physician services. You say that this was correctly billed with the 
inpatient place of service code. The Plan denied your request. The Plan says the enrollee was an outpatient 
during this hospital stay. As such, the place of service code is not correct. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 We find that CPT code 99223 is not supported in the medical record. Specifically, this code is to be used for 
inpatient hospital stays. The Plan has provided documentation showing that this hospital stay was outpatient 
observation. Based on this information, we decided that Medicare rules for coverage of the inpatient physician 
services have not been met. Therefore, we decided that the Plan does not have to pay for the initial inpatient 
physician visit provided on April 28, 2022, billed with code 99223.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on May 
28, 2022. 
 
You asked the Plan to waive the copayment for diagnostic test. You say that you are disputing the cost share. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for Medicare-covered outpatient diagnostic test.  
 
You have been asked to pay $10 copayment for diagnostic test. This item/service falls within the Medicare-
covered outpatient diagnostic test 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 
outpatient diagnostic test provided on May 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit an open bone biopsy (CPT 20240) 
provided to the enrollee on May 3, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the bilateral procedure must reported with one unit of sevice, no modifier, on one claim line. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Codes with an MAI of 3 represent that it would be possible but medically highly unlikely that higher MEU values would represent correctly reported medically 
necessary services. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the additional unit at 
issue in this case was not supported in the medical records. Our reviewer found that the medical records do not 
support the billing of the additional unit of CPT 20240. This additional unit is also not medically necessary. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional unit an open bone biopsy (CPT 20240) provided to the enrollee on May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says a referral/authorization was not obtained prior to services being rendered. 
 
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 had network providers available who could have provided 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 an office visit provided on March 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and tennis elbow procedure provided from 
January 4, 2022, to January 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and tennis elbow procedure. You say that the provider has treated 
this patient before, and the services were medically necessary. The Plan denied your request. The Plan says 
referrals/authorizations were not obtained prior to services being rendered. 
 
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 had network providers 
available who could have provided 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 an office visit and tennis elbow procedure 
provided from January 4, 2022, to January 28, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab test provided on June 09, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab test. You say that you are requesting reconsideration because the doctors 
office failed to send in the preauthorization form for approval.The Plan denied your request. The Plan says the 
enrollee's network primary care physician (PCP) or plan must give the enrollee approval in advance before the 
enrollee can use providers not in the plan's network. This is called giving the enrollee a "referral." For more 
information about this and situations when the enrollee can see an out-of-network provider without a referral 
(such as an emergency), see Sections 2.2 and 2.3 of this chapter. If the enrollee doesn't have a referral (approval 
in advance) before the enrollee get services from an out-of-network provider, the enrollee may have to pay for 
these services their self. 
 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 had network providers 
available who could have provided 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 lab test provided on June 09, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PDE modular composite spring system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary, as the current brace has 
not been providing any positive change in symptoms or function. The Plan denied your request. The Plan says 
the plan does not cover duplicate or redundant prosthetic devices/durable medical equipment such as PDETM 
Modular Composite Spring System, when the second item performs the same function as the one currently 
provided to the enrollee. 
 
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 system. Our reviewer says that the 
requested system is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the requested device is used for the ankle and foot. The requested device has not been 
shown to be superior to other standard treatments for the medical condition.  The studies do not indicate the 
PDE Modular Composite Spring system improves an individuals function or general health more than the 
standard ankle foot orthosis. The requested device 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the PDE modular composite spring system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are 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 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 admission are met in this 
case. Our physician reviewer found the record provided does not indicate that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical 
factors. The initial day may be spent in observation until it is clearly expected that a second midnight would be 
required, at which time the physician may order inpatient admission. The elements of the coverage criteria are 
not satisfied. The requested service is not recommended. 
 
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 acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on June 15, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you were not informed you would 
have any charges. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for injections. This item/service falls within the Medicare Part B 
prescription drugs 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 coinsurance for injections provided 
on June 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee still needs therapy to be able 
to use body functions. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee no longer has documented skilled nursing needs.  No 
wound care needs are identified.  The enrollees feeding tube is established. The enrollee does not have 
documented skilled therapy needs. The enrollee has reached a plateau in function given his baseline 
hemiparesis. The enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a 
lower 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 care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 11000 and 15271 provided on 
October 5, 2021. 
 
You asked the Plan to pay for the medical services as billed. You say that you would like this claim 
reprocessed based on the medical records that have been submitted. The Plan denied your request. The Plan 
says the billed codes are not supported in the documentation submitted. 
 
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 11000 is debridement of extensive eczematous or 
infected skin; up to 10% of body surface. The CPT Code Manual definition of code 15271 is application of 
skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound 
surface area. 
 
We asked our coder 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 medical services as billed. Our reviewer says that the 
documentation does not support payment for the services as they were billed. Our reviewer found that for CPT 
15271, the procedure report does not include documentation of application of skin substitute graft area up to 
100 sq cm; first 25 sq cm or less. Procedure report documents "Allograft #8 to R buttock completed - graft 
needs to remain in place". Medical record has insufficient documentation to confirm CPT code description has 
been performed in this case. Regarding CPT 11000, the procedure report does not include sufficient 
documentation to confirm extensive debridement.  Procedure report documents "Cleanse sacral wound with 
dermal cleanser". Debridement is the removal of dead (necrotic) or infected skin tissue to help a wound heal". 
Documentation describes the wound was cleansed, and therefore, extensive debridement cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services coded 11000 and 15271 provided on October 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab 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 the clinical information submitted does not support medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that there are no PDL-1 
results. This regimen is supported as Carboplatin, Taxol, Avastin-Zirabev, along with the requested 
Keytruda/Pembrolizumab. The single agent is not supported over the four drug regimen. 
 
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 Pembrolizumab for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continuation of SNF care. You say that continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says continuation of SNF care does not meet the 
Medicare coverage criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 continuation of SNF care. Our reviewer 
says that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found that based on the documentation provided, the enrollee no longer 
qualifies for SNF coverage after October 10, 2022. The enrollee does not have documented skilled nursing 
needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 
feet and tending to activities of daily living with supervision. Daily skilled services are not shown to be 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs can, as a practical matter, be provided at a lower level of care  
(ex. home, assisted living, long term 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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation SNF care.