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 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 you appear to be improving but are still somewhat unstable and should only require 
short-term additional acute care services that can safely be completed at the current facility until more stable 
and appropriate for a lower level of care. There are no services at the LTACH that you require that are not 
already available and covered at the current facility. Transfer to a lower level of care may be considered when 
treatment is completed. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances independently with a cane and is independent for transfers and activities of daily living. 
Provided records do not document a significant decline in your functional status to necessitate daily inpatient 
skilled therapy services. You do not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Records do not document that services in the outpatient setting or in the home with home health care 
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: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the urgent care visit provided on October 9, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the provider requested you 
pay $50 as a deductible, and you paid it. You say that you confirmed the provider is an urgency center and are 
requesting reimbursement. The Plan denied your request. The Plan says that the $50 copayment applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees pay a $0 copayment for an urgent room visit. 
 
The Plan says you must pay a $50 copayment for an emergency room visit. Based on the Plan contract, 
however, you cannot be asked to pay more than $0 copayment for an urgent care visit. The records show the 
National Provider Identifier (NPI) billed on the claim is for the entire health group, not the specific facility you 
were seen at. In addition, the Place of Service (POS) billed on the claim is for an urgent care facility. 
Therefore, we decided that the Plan has to waive the copayment for the urgent care visit provided on October 9, 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on July 5, 2021. 
 
You asked the Plan to pay for the podiatry services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from June 22, 
2021, to July 29, 2021. The Plan says that, per Medicare, the provider must bill Original Medicare for the 
services provided on July 5, 2021. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the podiatry services provided on July 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission will be able to provide the 
physical, occupational and speech therapy that the enrollee needs to come home and live her life that she had 
before her major surgery 8 months ago. The Plan denied your request. The Plan says records do not show that 
the enrollee needs to be seen by a rehab doctor three times per week, that they can participate in intensive 
therapy or that they need to be seen by an interdisciplinary team. 
 
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 while the enrollee may benefit from PT, and OT, her rehab needs can be 
addressed at a low intensity alternate setting such as in a SNF. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services the enrollee needs in other 
settings. 
 
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for gangrene of the toe 
and peripheral artery revascularization. The enrollees medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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 given the enrollee's current level of function it is 
reasonable to assume that she will be able to meet her goal of independence after a short stay at an IRF where 
she will receive 3 hours of physical therapy (PT) and occupational therapy (OT) 5 days a week. The Plan 
denied your request. The Plan says IRF care 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 while the enrollee has a need for physical and/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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) receiver (K0554) and 
supplies (K0553), provided on August 25, 2021. 
 
You asked the Plan to pay for the CGM receiver and supplies. You say that the items should be covered. The 
Plan denied your request. The Plan says there is not valid proof of delivery submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. No proof of delivery was submitted. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) receiver (K0554) and 
supplies (K0553), provided on August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 16, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on July 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy (OT) services (97110 and 97535) 
provided on July 21, 2021 by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the OT services. You say that these services were provided in good faith due to 
medical necessity. The Plan denied your request. The Plan says the treating provider is non-participating and 
prior authorization was not obtained before rendering services. The Plan also says that the documentation 
submitted did not show that this procedure was part of an emergency service. 
 
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. 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 occupational therapy (OT) services (97110 and 97535) provided on July 21, 2021 by an out-of-network 
(OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground ambulance mileage (A0425) provided on October 
18, 2021. 
 You asked the Plan to pay for the ambulance mileage. You say that these services were necessary and should 
be paid. The Plan denied your request. The Plan says no more than 250 units can be reported for A0425 in a 
single claim line. This claim needs to be corrected in order to be processed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a code has an MAI of 1, appropriate use of a 
modifier may be used to report the same HCPCS/CPT code on separate lines of a claim. Each line of the claim 
with that HCPCS/CPT code will be separately adjudicated against the MUE value for that code.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 335 units of 
this code on a single line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of the ambulance mileage have not been met. Therefore, we decided that the Plan does not have to 
pay for the ground ambulance mileage (A0425) provided on October 18, 2021.
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 continued SNF care is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says medical necessity rules for continued SNF care 
have not been met. 
 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 daily skilled services are not necessary. Our physician reviewer found that the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
appears to be at/near a new, lower plateau in function. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Renflexis. 
 
You asked the Plan to pre-approve Renflexis. You say that the enrollee tried Xeljanz but stopped due to the 
cost. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because 
the plan requires a trial of Humira, Enbrel, Xeljanz, or Rinvoq before it will approve Renflexis. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Renflexis. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Renflexis. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Humira, Enbrel, Xeljanz, or Rinvoq. 
The record does not show that these drugs would likely be less effective and/or have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Renflexis.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from July 1, 2021, to 
July 21, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you had been quoted by a Plan 
representative on September 22, 2021 that the Plan did not need a RAP and only a final was needed. The Plan 
denied your request. The Plan says the non-contracted provider did not submit the RAP claim for services for 
dates of service July 1, 2021, to July 21, 2021 until August 6, 2021. The Plan also says that no exception 
request was submitted to the Plan to waive the 5-day requirement for filing the RAP claim due to a 
circumstance beyond the providers control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have 
to pay for the home health care services provided from July 1, 2021, to July 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 7 to 8 nerve conduction studies (95910) and needle 
electromyography (95886) billed for date of service May 20, 2021. 
 You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that the services 
at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says the services at 
issue are not supported in the available medical records. 
 
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 95910 is "Nerve conduction studies; 7-8 studies." 
 
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 nerve conduction studies. Our reviewer says that nerve 
conduction studies do not meet criteria for reimbursement. Our reviewer found that the procedural report does 
not support that 7 to 8 studies were completed. CPT code 95910 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve conduction studies have not been met. Additionally, we have confirmed 
that code 95886 is an add-on code and has not been billed with an appropriate primary procedure code. Based 
on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does 
not have to pay for 7 to 8 nerve conduction studies (95910) and needle electromyography (95886) billed for 
date of service May 20, 2021.
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 daily skilled nursing services are required for the 
intravenous vancomycin via the peripheral central catheter. The enrollee requires the services on an inpatient 
basis, in a skilled nursing facility setting. Records comment on the family's inability to manage the intravenous 
antibiotics at home. 
 
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.