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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
November 7, 2021, through November 20, 2021. 
 
You asked the Plan to pay for these services. You say that the inpatient hospital care provided was medically 
necessary. The Plan denied your request. The Plan says the inpatient hospital care provided was not medically 
necessary. 
 
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 pay for these services. Our reviewer says that the 
services provided are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was admitted to the hospital on October 9, 2021 for falls and an altered mental status. 
The enrollee was found to have Dilantin toxicity with a level of 28.7.  It was documented that the enrollee was having increasing difficulty caring for herself at home, with this 
admission being her second for phenytoin toxicity. A psychiatry evaluation determined that the enrollee had a 
major neurocognitive disorder. The enrollees condition improved with IV fluids, and discontinuing the 
Dilantin. The seizure medication was changed and the enrollees mental status improved. The documentation 
indicates that on November 2, 2021 the enrollee was stable to discharge and was pending an approval for 
placement in an Assisted Living Facility. Additionally, the progress notes of November 7, 2021 indicate the 
enrollee was waiting for placement in an Assisted Living Facility. The enrollee was then discharged to an 
Assisted Living Facility on November 20, 2021. The documentation does not support that the continued 
inpatient hospital care provided from November 7, 2021, through November 20, 2021 was medically 
reasonable and necessary for the enrollee in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from November 7, 2021, through November 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy, manual therapy, and self-care 
management training provided on December 17, 2021 to December 28, 2021, by an OON provider. 
 
You asked the Plan to pay for occupational therapy, manual therapy, and self-care management training. You 
say that you would like the medical records to be reviewed and the claim to be reprocessed and paid. The Plan 
denied your request. The Plan says the out-of-network services were not authorized. 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 occupational therapy, manual therapy, and self-
care management training provided on December 17, 2021 to December 28, 2021, by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan provided on November 10, 2021. 
 
You asked the Plan to pay for the CT scan. You say that you would like this reprocessed for payment. The Plan 
denied your request. The Plan says original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a computed tomography (CT) scan provided on November 
10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit (99350) and advance care planning 
(99497) provided on February 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit and advance care planning. The Plan denied your request. 
The Plan says the provider and referring physician are out-of-network. 
 
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 the home health visit (99350) and advance care 
planning (99497) provided on February 24, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on November 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the genetic testing services provided on November 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotic device (L1690) provided on February 24, 2022. 
 
You asked the Plan to pay for the orthotic device. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the medical records do not support the 
medical necessity of the ordered equipment. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support the medical necessity for the supplies 
provided in this case. In this case, the medical records do not indicate that the ordering provider discussed the 
medical need for the ordered equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the orthotic device (L1690) provided on February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stair lift provided on November 29, 2021. 
 
You asked the Plan to pay for the stair lift. You say that you had this installed so you could remain in your 
home. The Plan denied your request. The Plan says Medicare does not cover modifications to the home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the stair lift provided on November 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF admission is not medically necessary based lack of medical complexity and 
acute rehabilitation nursing needs. The document does not support the necessity for admission to an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no documentation to support the need for a skilled therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy 
generally is not accepted as specific and effective therapy for the patients condition beyond what was 
approved by the health plan. The patient has had prior extensive therapy approved and the documentation does 
not reveal that the patient's requires the unique skills of a professional therapist to safely and effectively 
provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under 
the supervision of a therapist. The requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. The 
patient has had prior instruction in a home exercise program. The patient should have follow up with her 
treating physician for worsening pain. Ten more skilled therapy sessions are 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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and a supply 
allowance (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and a supply allowance. You say that the enrollee has a phobia of 
needles and needs the CGM to monitor sugars with the stick of the needle. The enrollee has ongoing and 
elevated sugars for a long time, and he needs to get it under control. The Plan denied your request. The Plan 
says the enrollee does not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day and use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a CGM and a supply allowance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and a 
supply allowance (K0553, K0554).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee was recently hospitalized for a stroke with significant hemiparesis. She required surgical 
intervention to address an AV fistula. She requires rehabilitation physician oversight regarding her medical 
condition after her stroke, including frequent monitoring of her neurological status and medications. She 
requires rehabilitation nursing for management of her neurogenic bowel and bladder and family training for 
discharge to home. The enrollee does require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. She has had a significant decline in her baseline function due 
to a stroke. She requires maximum assistance for transfers and standing and dressing. When initially assessed, 
she did not have the ability to actively participate in therapies, but now she can follow commands and 
participate in therapy. She also requires speech language pathology to assess and follow her dysphagia as well 
as her aphasia. She would benefit from the intensive therapies provided in the acute inpatient rehabilitation 
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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on January 25, 
2021. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered for 
screening. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on January 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 4, 
2022. 
You asked the Plan to pay for procedure code 76705. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.  
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, we have confirmed that code 76705 
has a bundled relationship with code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving the care he needs in the hospital 
where he is now and there is no need to transfer to the LTACH at this time. 
 
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. The enrollee 
was admitted with respiratory insufficiency secondary to sepsis from infected extremity wounds. The record 
indicates that at the time of transfer to the LTACH the enrollee still required acute care services before 
transitioning to a lower level of care. The enrollee could have continued to receive acute care services at the 
acute care facility and those services had not been denied. The medical record does not indicate that the 
enrollee required services that he was not receiving but that were available at the LTACH facility. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.  
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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that this admission does not meet the intensity of 
services required for inpatient admission. 
 
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The documentation 
pre-operatively shows that the member has a history of underlying seizures. Therefore, at the time of admission, the request for an inpatient care does not meet the threshold for an intensity of services or 
underlying member hemodynamic instability that could only be managed in an acute inpatient setting. The 
record does not show that at the time of inpatient admission the admitting physician reasonably expects that the 
patient's necessary hospital care would span two midnights. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99291) provided January 1, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99291 is a critical care visit of 30-74 minutes. 
 
 
 
 
 
 
 
 
 We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show how 
much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of 
the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (99291) provided January 1, 2022.