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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care, daily complex wound care or respiratory care. There 
is no documentation that daily skilled services are required. Although records document the enrollee is very 
limited functionally, provided records do not document a significant decline in the enrollee's functional status 
compared to her recent baseline (or the ability to participate with therapy) to necessitate daily inpatient skilled 
therapy services. The enrollee does not require the services on an inpatient basis, only in a skilled nursing 
facility setting. Records do not document that services in the long-term care facility on a part time basis are not 
appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 clinical documentation shows that the enrollee has multiple comorbidities that are active and require 
close medical supervision on an inpatient basis. Evaluating therapists (PT, OT) state that the enrollee requires 
intense and multi-disciplinary rehabilitation and that he would significantly benefit from intense rehabilitation 
thus IRF criteria have been met. 
 
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: 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 needs an extension of her 
stay at the SNF for further evaluation and speech rehab to try and improve her condition prior to returning 
home. The Plan denied your request. The Plan says the enrollee is covered for 100 days per benefit period. The 
Plan also says records show that the enrollee has used 100 days of skilled nursing facility benefits by 8/6/22. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from April 5, 2022, 
through August 6, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. 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 hospital discharge day management services provided on 
March 9, 2021. 
 
You asked the Plan to pay for hospital discharge day management services. The Plan denied your request. The 
Plan says Medicare denies a claim if it is not received by the plan within 12 months or 1 calendar year from the 
date when the services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for hospital discharge day management services was not filed until 
March 17, 2022. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for hospital discharge day 
management services provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gloves (A4930) provided on March 25, 2022. 
 
You asked the Plan to pay for gloves. You say that this was an emergency, and the payment was lower than 
your expenses. The Plan denied your request. The Plan says this cannot be paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that an Outpatient Prospective Payment System 
(OPPS) payment status indicator is assigned to every procedure code. Services with status indicator N are paid 
under the OPPS, but their payment is packaged into payment for a separately paid service.  
 
We looked at the file and Medicare rules. The billed code, A4930, has a status indicator of N and is not paid 
separately. Based on this information, we decided that Medicare rules for coverage of gloves have not been 
met. Therefore, we decided that the Plan does not have to pay for gloves (A4930) provided on March 25, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FANCC genetic testing rendered on January 3, 2022. 
 
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 that the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan references Local Coverage Article (LCA) A53628 in their 
determination; which is not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the FANCC genetic testing rendered on January 3, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on January 10, 2022. 
 
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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services 
rendered on January 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on October 2, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. 
 Therefore, we decided that the Plan does not have to pay for the testing services rendered on October 2, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient admission and stay provided to the enrollee from October 
30, 2021, to November 6, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that this cannot be approved because there is no evidence of a high 
fever. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the inpatient admission and stay provided to the enrollee from October 30, 2021, to November 6, 
2021.  
 
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 Prometheus IBD sgl Diagnostic testing rendered on 
March 21, 2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Prometheus IBD sgi Diagnostic test is non-
covered. 
 
We looked at the file and Medicare rules. The testing at issue is the Prometheus IBD sgi Diagnostic testing. 
This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
Prometheus IBD sgl Diagnostic testing rendered on March 21, 2022.
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 items are necessary for you. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Knee Orthosis (L1845). 
 
You asked the Plan to pre-approve a Knee Orthosis (L1845). You say that the requested Knee Orthosis (L1845) 
is medically necessary for the enrollee's diagnosis. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for the requested Knee Orthosis (L1845). 
 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 a Knee Orthosis (L1845). Our reviewer 
says that the enrollee does not meet criteria for the requested Knee Orthosis (L1845). Our physician reviewer 
found the enrollee was being treated for unilateral primary osteoarthritis of the left knee. She presented with 
left knee pain, which is occasionally worse, though not consistently worse. She denies instability. Her knee 
feels a little bit swollen. The exam reveals mild effusion about the left knee. There is continued lateral proximal 
tibial tenderness. McMurrays is positive. The range of motion is full. 
 
However, detailed documentation is not evident regarding any recent surgery or injury to the left knee. 
Additionally, the exam from May 25, 2022, did not demonstrate any instability. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the enrollee does not meet Medicare criteria for the requested Knee 
Orthosis (L1845). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Knee Orthosis (L1845) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Knee Orthosis (L1845).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 28, 2022, to 
January 30, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says that an inpatient admission was not medically 
necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 28, 2022, to January 30, 2022.  
 
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 lab services (83789) provided February 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for lab services (83789) provided February 14, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
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 SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found records do not document the need for intravenous 
medications, new tube feeding, ostomy care, daily complex wound care or respiratory care. There is 
documentation that daily skilled physical therapy and occupational therapy services are required. Provided 
records from physical therapy and occupational therapy in the nursing facility document a significant decline in 
the enrollees functional status compared to his recent baseline to necessitate daily inpatient skilled therapy 
services. The enrollee requires the services on an inpatient basis in a skilled nursing facility setting. Family 
report they are no longer able to manage him at home and daily therapy services appear to be appropriate. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that non-sterile gloves are not covered because they are 
hygienic items that are non-reusable. 
 
We looked at the file and Medicare rules. The services at issue are non-sterile gloves. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-sterile gloves.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory testing rendered on August 19, 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 code 0202U is not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure code 0202U is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue was billed with procedure code 0202U. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the respiratory testing rendered on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided January 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary. The Plan denied 
your request. The Plan says this test is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered. 
 
We looked at the file and Medicare rules. The panel tested for 6 or more pathogens. 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 lab services provided January 17, 2022.