Persius/hicric huggingface dataset:
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 trying to be admitted into an inpatient 
therapy facility so that you can get better and be discharged from the hospital. The Plan denied your request. 
The Plan says the record shows that you do not meet the Medicare guidelines for services in an inpatient 
rehabilitation facility. 
 
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 you were admitted for falls, pulmonary embolism, and infection of the knee joint 
after recent knee replacement surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the insertion of gastrostomy tube (49440) provided on September 22, 
2021. 
 
You asked the Plan to pay for the insertion of gastrostomy tube (49440). You say that the attached medical 
reports support the service, and the claim should be reprocessed for payment. The Plan denied your request. 
The Plan says that this surgery is included in the 10-day global period of 36558. 
 
The Plan must follow Medicare rules. Medicare rules say that clearly distinct surgical procedures and services 
of other physicians during the postoperative period are not included in the global surgery package.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the insertion of gastrostomy tube (49440) have not been met. Specifically, the insertion of 
gastrostomy tube (49440) was performed by a different physician and is an unrelated procedure to the service 
performed on September 17, 2021. Therefore, we decided that the Plan has to pay for the insertion of 
gastrostomy tube (49440) provided on September 22, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service February 27, 
2022. 
  You asked the Plan to pay for procedure code 71045. You say that CPT code 71045 is not inclusive to any 
other CPT code on this date of service. You say that the medical records substantiate the medical necessity, and 
this service is eligible for separate payment. The Plan denied your request. The Plan says payment for code 
71045 is bundled into payment for code 71046. 
 
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 71045 
is a column II code to column I code 71046. 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 71045 billed for date of service February 27, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services 
 
You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. 
The Plan says that all services that would be provided in the SNF are already being given in the current 
inpatient rehabilitation facility (IRF) setting. 
 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 services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee 
is ambulating more than 100 feet and tending to activities of daily living (ADLs) with varying levels of 
assistance.  The enrollee is likely at/near a plateau in function given his dementia.  Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition.  The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says 
that the enrollee can safely go to a different setting and receive therapy less than daily to maintain function. 
 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 services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs.  The enrollee does not have 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, custodial and intermittent, can, as a practical matter, be provided at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (Q0092, R0075) provided on December 19, 
2021. 
 You asked the Plan to pay for imaging services. You say that these services were reported correctly and are 
payable. The Plan denied your request. The Plan says this claim was submitted with an incorrect POS code, as 
the enrollee was not in a Part A covered nursing facility stay. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. 
 
We find that POS code 31 is not supported in the medical record. Specifically, the enrollee was not in an 
approved (Part A covered) skilled nursing facility admission at the time of services. This means that POS code 
32 would be more appropriate in this case. Based on this information, we decided that Medicare rules for 
coverage of imaging services have not been met. Therefore, we decided that the Plan does not have to pay for 
imaging services (Q0092, R0075) provided on December 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on January 12, 
2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there was no 
documented contact with the attending/primary physician. The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document the date the 
patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not 
succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. The record does not include documentation of a consultation or an 
attempt to consult the enrollee's primary/attending physician as required by Medicare rules. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the outpatient mental health services provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided by an out-of-network 
provider on February 24, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you have been at this place for years and 
would like to back in this network. The Plan denied your request. The Plan says you must receive care from a 
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 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 
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 outpatient services provided by an out-of-
network provider on February 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTAC admission 
criteria. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care 
and does not require transfer to a LTACH. 
 
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. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. 
 
 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 the 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 have fallen several times at home and it is not 
safe to be at home alone. The Plan denied your request. The Plan says based on Medicare guidelines the IRF 
services you are requesting do not meet the requirements for approval. 
 
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 you were evaluated in the emergency department on August 4, 2022 for a fall and 
urinary tract infection and was discharged home. There is ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. While you have a need for physical or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 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, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on March 9, 
2022. 
 
You asked the Plan to pay for the critical care services. You say that this service was coded correctly and 
should be paid. The Plan denied your request. The Plan says the documentation does not support payment for 
this code 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, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
record the time spent providing critical care services. Based on this information, we decided that Medicare 
rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not 
have to pay for the critical care services coded 99291 provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 18, 2022, billed 
with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81335 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that the genetic testing at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for genetic testing 
have not been met. 
 
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 18, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 
81328, 81335 and 81355.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided from January 11, 2022, through 
January 26, 2022. 
 
You asked the Plan to pay for the inpatient hospital care. You say that this claim was denied incorrectly as 
being payable by a liability carrier. There is no liability insurance as the enrollee fell at home which is why this 
care was necessary. The Plan denied your request. The Plan says that since this injury was the result of an 
accident, Medicare payment is only made when liability or no-fault insurance is exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make primary payment if 
payment has been made or can reasonably be expected to be made by liability or no-fault insurance. If such 
coverage is expected but not reasonably expected to be made promptly, then conditional payment can be made.  
 
We looked at the file and Medicare rules. The records show that the enrollee was admitted with a hip fracture 
caused by a fall in her private home. There is no evidence in the file that there is a liability or no-fault payer 
that can be reasonably expected to cover this injury. The Plan has provided no evidence that such alternate 
coverage exists, and as no claim has been filed with a primary payer, payment cannot be expected promptly. 
Given the lack of a viable primary payer, we find that, at the very least, conditional payment should be made. If 
the Plan identifies a liability or no-fault insurer that would be required to cover the injury, the Plan may request 
repayment of the cost of this admission from that payer. Based on this information, we decided that Medicare 
rules for coverage of the inpatient hospital care have been met. Therefore, we decided that the Plan has to pay 
for the inpatient hospital care provided from January 11, 2022, through January 26, 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: 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 inpatient therapy would be the best form of treatment 
for your condition. The Plan denied your request. The Plan says based on Medicare guidelines the IRF services 
you are requesting do not meet the requirements for approval. 
 
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 you are living at home with progressive lower extremity weakness, prediabetes, hypertension and an abdominal wall abscess. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gum excision procedure you had on December 7, 2021. 
 
You asked the Plan to pay for the gum excision procedure. You say that this was an emergency and should be 
covered. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. The gums are structures directly supporting the teeth.  
The procedure you had was related to the gums. As a result, this procedure is considered a dental service that is 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the gum 
excision procedure you had on December 7, 2021.