Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to take care of yourself at home. You 
state you had a stroke and need the physical therapy. The Plan denied your request. The Plan says the stay is 
not medically necessary based on SNF criteria. The Plan states you have completed your intensive course of 
care at the IRF, and intermittent therapy can safely be received at a different setting, for example, home with 
home health or outpatient therapy in residential 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found admission to an SNF is not reasonable and not 
necessary as you have no skilled nursing needs and do not need skilled therapies on a daily basis in an inpatient 
setting at the current functional level. You have made minimal progress with aggressive IRF level of therapies. 
Continued therapy in an SNF is unlikely to change your functional status. Documentation does not support the 
need for an admission to an SNF. While you may benefit form physical therapy (PT), occupational therapy 
(OT), and speech therapy (ST) with anticipated delayed recovery from a cerebrovascular accident (CVA), your 
rehabilitation needs can be safely met at a lower intensity level such as in an SNF with intermittent therapy 
services. Your record does not show that you require daily skilled nursing or skilled therapy in an SNF setting. 
The services you require are at custodial care level given the extent of your deficits. 
 
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 pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on February 10, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was 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 testing have not been met. Therefore, we
decided that the Plan does not have to pay for the genetic testing provided on February 10, 2021.
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 transfer to an LTACH is medically 
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an 
LTACH are not met. The enrollee does not have complex wound care needs, has not been receiving ventilator 
support, and does not have long term IV medication needs. His needs can be safely met in a lower 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be stable and improving and requires only short-term 
additional acute care services which can safely be administered at the current facility. The enrollee does not 
require services at the LTACH that are not already available and covered at the current facility. Transfer to an 
LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care 
may be considered when treatment has completed.  
 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 pre-approve a pain management visit to be provided by an out-ofnetwork (OON) provider.
You asked the Plan to pre-approve a pain management visit. You say that there is no in-network provider who
can provide the service you need. The Plan denied your request. The Plan says there is a referral to an innetwork provider that can provide the same service as the out-of-network provider.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a pain management visit to be provided by an out-of-network (OON) provider.
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 currently meets the LTACH 
admission criteria. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
LTACH services do 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 the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where she is currently receiving care. The 
documentation does not support that the requested LTACH services are medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 28, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and the urine capacity measurement 
(51798) rendered by the out-of-network (OON) provider on October 21, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the office visit (99213) and the urine capacity measurement (51798) rendered by 
the out-of-network (OON) provider on October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral upper or lower extremity arterial assessments to 
check blood flow in relation to a blockage provided on October 12, 2021. 
 
You asked the Plan to pay for bilateral upper or lower extremity arterial assessments to check blood flow in 
relation to a blockage. The Plan denied your request. The Plan says 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 
Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 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 bilateral upper or lower extremity arterial assessments to check 
blood flow in relation to a blockage provided on October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the xT Solid Tumor + Normal and xF Liquid Biopsy Tempus
gene panels provided on May 3, 2021 and billed with CPT codes 81191, 81317, 81321, 81206, 81210, 81235,
81272, 81275, 81276, 81292, 81295, 81298, 81301 and 81311.
You asked the Plan to pay for the Tempus panel. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says these services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene
CPT codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Tempus panel have not been met. Specifically, this claim was billed with individual CPT
codes. This is not considered correct coding. Therefore, we decided that the Plan does not have to pay for the
xT Solid Tumor + Normal and xF Liquid Biopsy Tempus gene panels provided on May 3, 2021 and billed with
CPT codes 81191, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301
and 81311.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT
code 70450) provided to the enrollee on October 13, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your
request. The Plan says the service is not covered as billed.
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 70450
is a column II code to column I code 70496. 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 the CT scan, head or brain; without contrast material (CPT code
70450) provided to the enrollee on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging and surgical services rendered on September 7, 
2021. 
 
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 procedure codes 20936 and 72295 are not separately payable. 
 The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 20936 has a status indicator of B and no 
separate Medicare payment. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 72295, 76000, and 22558. Codes 72295 and 76000 are 
column II codes with a modifier indicator of 1 when billed with column I code 22558. Codes 72295 and 76000 
were not billed with an appropriate modifier to allow for separate payment. The -59 modifier is not supported 
as a separate and distinct procedure service. Therefore, we decided that the Plan does not have to pay for the 
imaging and surgical services rendered on September 7, 2021.
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 cannot be adequately cared
for in his current condition at a skilled nursing facility as he requires direct daily physician assessment. The
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage.
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 a transfer to LTACH is not medically necessary as it would not be clinically
advantageous. Transfer to a lower level of care may be considered when treatment has been completed.
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care services provided on September 26, 
2021. 
 
You asked the Plan to pay for the emergency care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the enrollee had a primary insurance that was not this health plan. 
 
 
 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan needs the 
primary insurance Explanation of Benefits (EOB). As the secondary insurer, the Plan cannot be held 
responsible for the emergency care services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the emergency care services provided on 
September 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollees condition; the enrollee does not meet the 
requirements. 
 
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 that the documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a days /5 day 
a week, or 15 hours over 7 consecutive days, of therapy services. Services may 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
March 12, 2021. 
 
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 order. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies rendered on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you have tried several in-network 
providers and made no progress. The Plan denied your request. The Plan says there is currently a referral with 
an in-network provider. There also has been other in-network providers given to the enrollee if they need 
services sooner. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve a sleep study. The Plan denied your request. The Plan says enrollees must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the Plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the Plan. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a sleep 
study to be provided by the requested out-of-network provider.