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 LTACH is the appropriate level of 
care, and that the enrollee is medically stable for transfer to LTACH level of care. The Plan denied your 
request. The Plan says the LTACH is not medically necessary, and the enrollee's needs are being met at the 
current care 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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 a prolonged evaluation and management service (99358) 
billed for dates of service March 2, 2022, to March 5, 2022. 
 
You asked the Plan to pay for a prolonged evaluation and management service. You say that you have provided 
records to support the services billed. The Plan denied your request. The Plan says the records do not support 
the code at issue. 
 
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 99358 is "Prolonged evaluation and management service 
before and/or after direct patient care; first hour." 
 
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 a prolonged evaluation and management service. Our 
reviewer says that the services billed do not meet criteria for payment. Our reviewer found that the available medical records do not support the use of procedure code 99358 as there is no documentation that states the 
service rendered was prolonged. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a prolonged evaluation and management service have not been met. Therefore, 
we decided that the Plan does not have to pay for a prolonged evaluation and management service (99358) 
billed for dates of service March 2, 2022, to March 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with an out of network (OON) provider. 
 
You asked the Plan to pre-approve office visits with an OON provider. You say that you had emergency heart 
surgery and need to continue seeing the providers you saw during the hospital stay. The Plan denied your request. The Plan says the records show that the enrollee is not in an active course of treatment with the 
requested OON provider. The Plan says that they have confirmed with 2 participating providers that are able 
supply the services being requested and are accepting new patients. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 office visits with an OON provider. Our 
reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found there 
are credentialed, experienced physicians within the Plan's network who could be utilized for your clinical 
condition. There is insufficient documentation to support the medical necessity for referral to an OON provider 
for the needed office visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of office visits with an OON provider have not been met. Therefore, we decided 
that the Plan does not have to pre-approve office visits with an out of network (OON) provider.
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 requires close monitoring 
from a LTACH. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapy visits. 
 
You asked the Plan to pre-approve the home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for continued home 
health care services because your care needs are custodial. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 home health physical therapy visits. 
Our physician reviewer found you do not have documented skilled nursing or skilled therapy needs. As such, 
home health services are not shown to be medically necessary and reasonable. 
 
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 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390) and a battery provided on 
January 31, 2022. 
 
You asked the Plan to pay for an oxygen concentrator and a battery. You say that the provider offered the use 
of refillable oxygen tanks in lieu of having a concentrator. You are confined to a wheelchair and your wife is 
physically unable to assist with the tanks, therefore, your only option to leaving your home was to purchase a 
replacement portable concentrator. The Plan denied your request. The Plan says Medicare only covers rental of 
oxygen equipment, not purchases. 
 
The Plan must follow Medicare rules. Medicare rules say only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered.  
 
We looked at the file and Medicare rules. Medicare confirms that only rented oxygen equipment is eligible for 
coverage. The records show you purchased the oxygen equipment and reimbursement is not a covered benefit. 
Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator and a 
battery have not been met. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator 
(E1390) and a battery provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the services were medically necessary. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulatory infusion pump, single or multiple channels, 
electric or battery operated, with administrative equipment, worn by patient (E0781) provided on February 3, 
2022. 
 
You asked the Plan to pay for an ambulatory infusion pump. You say that you disagree with the denial and 
have submitted medical records for review. The Plan denied your request. The Plan says the provider is not 
eligible to perform the services billed. The provider is no longer credentialed or eligible for Medicare/Medicaid 
billing of services. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an ambulatory infusion pump, single or 
multiple channels, electric or battery operated, with administrative equipment, worn by patient (E0781) 
provided on February 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care from October 29, 2022, 
forward. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the continued inpatient stay at the 
acute facility is necessary. The Plan denied your request. The Plan says the continued stay is 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found as of October 28, 2022, the enrollee's chronic medical problems were 
medically stable, and the continuation of an acute hospital admission was no longer 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care from October 29, 2022, forward.
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 services 
are required. You are below your functional baseline and are receiving necessary and appropriate therapy in the 
acute facility. You are reported to be participating with and benefiting from the provided therapy. You do not 
require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in the acute 
rehabilitation hospital is appropriate until you are stable to transfer to a lower level of care such as home with 
home health care or to a long-term care facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 more stable and improving and should only require short-
term additional acute care hospital services at the current facility until more stable and appropriate for a lower 
level of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are bedridden, and your health is declining. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. Clinical documentation shows that you have functional impairments however there are no 
active medical comorbidities documented that would require inpatient hospitalization during rehabilitation. 
Medically necessary care can be provided in a different 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have 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 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for weakness. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in 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 inpatient rehabilitation facility (IRF) admission and services.
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 requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 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 qualifies for SNF coverage. The enrollee does 
not have documented skilled nursing needs or documented skilled therapy needs. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs are custodial and 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 23, 2022, billed 
with codes 81225, 81226, 81227, 81230, 81231, and 81381. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 23, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, and 81381.