Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON foot orthotics. You say that the requested provider has the type of 
shoes your doctor recommended. You say that the requested provider services directly to you in your home, 
which helps with your lack of transportation to multiple fitting appointments. You say that the network 
provider the Plan referred you to is too far away or they do not carry the shoes recommended by your doctor. 
The Plan denied your request. The Plan says medically necessary care is available in-network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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. Medicare rules say 
that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to 
an enrollee if contract providers are available within reasonable distance and travel time from the enrollees 
home. 
 
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 at issue in this appeal. We were able to confirm that the Plans contract 
provider is located 19 miles from your home, which is considered within reasonable distance and travel time 
from your home. Under Medicare rules, this means that contract providers are accessible to you. We found no 
exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not 
have to pre-approve foot orthotics to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 5 home health skilled nursing visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
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 5 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. Records 
document the enrollee/caregiver have been educated on her disease process and medications. No medical notes 
from the enrollee's treating physician are provided documenting an order or need for additional skilled nursing 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 5 home health skilled nursing visits.
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 enrollee will improve mobility, strength, 
endurance, balance, and safety to the highest potential with the least restrictive devices and return home with 
family. The Plan denied your request. The Plan says criteria for admission to the IRF have not been met. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for metabolic encephalopathy, dehydration, and pulmonary embolism. 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 this 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service June 20, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that the claim 
incorrectly denied. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, CPT codes 88341, 88342, 88360, and 88381 have a Professional/Technical indicator 
of 1. This means that CPT codes 88341, 88342, 88360, and 88381 have both a professional and technical 
component. In this case, CPT codes 88341, 88342, 88360, and 88381 has not been billed with an appropriate 
modifier to indicate the professional component. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service 
June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 29, 2021, to 
May 8, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
documentation supports the services as they were originally billed. The Plan denied your request. The Plan says 
the medical documentation submitted does not support the billed diagnosis A41.89. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code, A41.89, defined as other specified 
sepsis. 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 the inpatient hospital services at the DRG 
originally billed. Our reviewer says that the documentation does not support the billed diagnosis A41.89, 
defined as other specified sepsis. Our physician reviewer found that the patient had a history of underlying 
emphysema/chronic obstructive pulmonary disease (COPD) and recently diagnosed lung cancer with 
superimposed pneumonia. Mild hypoxia in this case is attributable to the direct impact of pneumonia on 
underlying baseline impaired pulmonary function due to emphysema/COPD and lung cancer, and is not 
reflective of a systemic dysregulated host response to infection. 
 
Per Medscape Internal Medicine,Sepsis  is a life-threatening syndrome usually caused by bacterial infection. 
Sepsis is a response of the body's immune system that results in organ dysfunction or failure. The systemic 
inflammatory response syndrome (SIRS) criteria were recently replaced by the quick Sequential Organ Failure 
Assessment (qSOFA) in 2016, allowing for quick bedside analysis of organ dysfunction in patients with 
suspected or documented infection. The qSOFA score includes a respiratory rate of 22 breaths/minute or more, 
systolic blood pressure of 100 mm Hg or less, and altered level of consciousness. For completeness, severe 
sepsis is defined as sepsis complicated by organ dysfunction. 
 
In this case, there is no clinical or laboratory evidence of sepsis. The review has determined that the 
documentation did not support the billed diagnosis code A41.89, defined as other specified sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 29, 2021, to May 8, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician pathology services provided on March 15, 
2022. 
 
You asked the Plan to pay for the physician pathology services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says these codes can only be 
paid if billed with modifier -26. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for TC services furnished in institutional settings where the TC service is bundled into the facility 
payment.  
 
We looked at the file and Medicare rules. The documentation supports that the enrollee was inpatient when this 
sample was taken. As such, the TC cannot be paid. Based on this information, we decided that Medicare rules for coverage of the physician pathology services have not been met. Therefore, we decided that the Plan does 
not have to pay for the physician pathology services provided on March 15, 2022.
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 records provided support the need for SNF care. 
The Plan denied your request. The Plan says the information they received does not show that the enrollee has 
completed their full course of care in the inpatient rehabilitation facility (IRF.) 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The records document the enrollee is tolerating and benefitting from therapy and 
treatment in the acute inpatient rehabilitation facility. Continued care in the acute inpatient rehabilitation 
facility is appropriate until the enrollee is stable to discharge to 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 6, 
2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $25 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a specialist office visit provided on June 6, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the IRF services 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 that the enrollee is deconditioned secondary to acute on chronic illness. The enrollee is confused. The enrollee does not require intensive rehabilitation services to regain function and has 
significantly reduced capacity to participate in or benefit from intensive therapy. She does not require frequent 
physiatry (physical medicine and rehabilitation) oversight. The enrollee is moderate assistance for transfers, 
ambulation and self-care. The enrollee has confusion and poor carryover during therapy. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436, 84479, 84480, and 85048 billed for 
date of service May 18, 2022. 
 
You asked the Plan to pay for procedure codes 84436, 84479, 84480, and 85048. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says payment for 
these codes have unbundled relationships with other codes billed and no separate payment is due. 
 
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 85048 
is a column II code to column I code 85025. 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. 
 
In this case, we have also confirmed that codes 84436 and 84479 are both column II codes to column I code 
84439 and code 84480 is a column II code to column I code 84481 with a modifier indicator of 0. The column 
II codes are therefore not payable. 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 codes 84436, 84479, 84480, and 85048 
billed for date of service May 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that home health aide services are 
necessary. The Plan denied your request. The Plan says the requested services are not medically necessary at 
this time. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health aide services. Our 
reviewer says that the requested home health aide services are not medically reasonable and necessary. Our 
physician reviewer found the home health aide in this case are requested for custodial services without a need 
for skilled services. Medicare provides for home health skilled services. The requested services are not 
medically necessary per chapter 7 are not medically necessary as they are custodial in nature.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 3 sensor. You say that the records provided support the 
need for the requested item. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for coverage. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections. In addition, the FreeStyle Libre 3 continuous glucose monitor is not a 
product that is specified in the PCL on the PDAC contractor website. That means that this device and all 
related items are non-covered. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre 3 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 3 sensor.
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 that the enrollee is in need for around the 
clock management of wounds. You say that the enrollee is unable to roll themselves and maintain side balance 
to reduce pressure to their wounds. You say that the enrollee is considered unstable due to chronic back pain. 
The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee 
can get the care they need at another 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 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. The health plan has approved ongoing care 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 9, 2021 to 
October 11, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.21. 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 the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the submitted records do not support the billing of diagnosis code J96.21. Our physician 
reviewer found the enrollee presented to the emergency room on October 9, 2021 with complaints of cough and 
chest pain. Her vital signs were normal and physical exam revealed decreased breath sounds int he left base. 
Chest x-ray was without infiltrates. There is no clinical or laboratory evidence of sepsis. The records do not 
support the billing of diagnosis code J96.21.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 9, 2021 to October 11, 2021, at the Diagnosis Related 
Group (DRG) originally billed.