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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 based on the medical records provided there is 
no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary 
and reasonable treatment. Records do not document the need for intravenous medications, new tube feeding, or 
ostomy care or daily complex wound care. This patient does require skilled therapy services, i.e., the 
specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide 
medically necessary and reasonable treatment. There is no documentation that daily skilled services are 
required. Although the patient is very limited functionally, he is actively resisting therapy and is not able to 
follow directions. There is no documentation that the patient requires the services on an inpatient basis, only in 
a SNF setting. Records do not document services in the home with home health care or in a long-term care 
facility on a part time basis (if the patient can participate) 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) and routine 
ophthalmological examination including refraction; new patient (S0620) provided November 5, 2021. 
 You asked the Plan to pay for the eye refraction and routine eye exam. You say that you were not aware that 
you did not have routine vision benefits. The Plan denied your request. The Plan says you do not have routine 
vision coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the determination of refractive state (92015) and routine 
ophthalmological examination including refraction; new patient (S0620) provided November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic test, unlisted molecular pathology 
procedure (81479) provided September 16, 2021. 
 
You asked the Plan to pay for the GeneSight Psychotropic test. You say that you request reconsideration of the 
original determination and cover the GeneSight Psychotropic test as medically necessary. The Plan denied your 
request. The Plan says the records do not support the services met Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the GeneSight Psychotropic test. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee has a diagnosis for 
which pharmacologic therapy is reasonable and necessary, and that the drug or drugs that the clinician is 
considering using are considered reasonable and necessary for the treatment of his diagnosis. 
 
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 GeneSight Psychotropic test have not been met. Therefore, we decided that 
the Plan does not have to pay for GeneSight Psychotropic test, unlisted molecular pathology procedure (81479) 
provided September 16, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services provided from June 16, 2021, to June 18, 2021. 
 
You asked the Plan to pay for the inpatient services. You say that you would like this claim to be reviewed and 
processed accordingly. The Plan denied your request. The Plan says that there was no documentation of a plan 
for an acute intervention or any other treatment to support an inpatient bill. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient services. Our reviewer says that 
the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care (including earlier emergency department and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient services have been met. Therefore, we decided that the Plan has to 
pay for the inpatient services provided from June 16, 2021, to June 18, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee is not currently appropriate for 
self-management with a home exercise program alone. The Plan denied your request. The Plan says the denial 
of authorization for additional physical therapy is correct, because the enrollee has improved and has been 
instructed in a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition beyond what was already approved by the Plan. The enrollee 
has had prior therapy and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, or that the services can be safely and 
effectively performed only by a therapist or under the supervision of a therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen. 
 
You asked the Plan to pre-approve Hydrocodone-Acetaminophen. You say that the enrollee has tried 
Acetaminophen with no result. You also say that this medication regimen is the next step in providing the 
patient relief resulting in his optimum health care. The Plan denied your request. The Plan says oral, self-
administered drugs are not a covered benefit under the Part B (medical) plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydrocodone-
Acetaminophen.  
 Benefits for Hydrocodone-Acetaminophen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiomyopathy testing provided on August 
26, 2021. 
 You asked the Plan to pay for the hereditary cardiomyopathy testing. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no 
Medicare benefit for cardiovascular risk assessment for asymptomatic patients. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the hereditary cardiomyopathy testing, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Of note, the documentation 
submitted does not include any clinical information to verify why this testing was ordered, if the enrollee is 
symptomatic, if the testing was medically necessary or how the results will impact the enrollee's treatment. 
Therefore, we decided that the Plan does not have to pay for the hereditary cardiomyopathy testing provided on 
August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies (CPT code 99072) provided on July 23, 
2021. 
 
You asked the Plan to pay for the supplies. You say that the claim should be paid. The Plan denied your 
request. The Plan says the supplies are not covered 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. 
 
CPT code 99072 has a status indicator of 'B' on the CMS Physician Relative Value File, is always bundled into 
payment for other services not specified and no separate payment is made per Medicare. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for additional supplies (CPT code 99072) provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service (CPT code 
99442) provided on September 6, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the 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 CPT code 99442 is telephone evaluation and 
management service by a physician or other qualified health care professional who may report evaluation and 
management services provided to an established patient, parent, or guardian not originating from a related E/M 
service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 
hours or soonest available appointment; 11-20 minutes of medical discussion. 
 
 We find that CPT code 99442 is not supported in the medical record. CPT code 99442 (1 unit) remains not 
supported. The documentation submitted did not support that a telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion was performed; therefore, the billed service cannot 
be verified. It is noted that multiple attempts were made to contact the provider for additional information. 
Based on this information, we decided that Medicare rules for coverage of the service have not been met. 
Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management service 
(CPT code 99442) provided on September 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient detox services provided on August 26, 2021, to 
September 4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient detox services. You say that you had to pay out-of-pocket for this. You 
say that you would like to be reimbursed for this. The Plan denied your request. The Plan says the member 
voluntarily left a participating facility. The Plan says that services must be provided 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 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 inpatient detox services provided on August 26, 
2021, to September 4, 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 ambulance services (A0429) provided on November 30, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that there was an issue with how this claim was 
processed. The Plan denied your request. The Plan says this claim was filed more than one year after the date 
of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until December 8, 2021. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance services (A0429) provided on November 30, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on December 18, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that by the time the paramedics got into your 
building your symptoms were gone. You say that the paramedics advised the hospitals were crowded and not to 
go to the hospital if you were not in dire need. You say that you decided not to go. You also say that you had 
another incident a few days later resulting in needing a stint put in. The Plan denied your request. The Plan says 
since no transport was provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 18, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.  
 
 Additionally, the record shows that you advised you did not want to go to the hospital as long as your vitals 
were good. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport, (A0998) provided on December 18, 2021.
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 needs to get out of the hospital, as it 
could make her more ill if she continues to stay. The Plan denied your request. The Plan says the guidelines for 
coverage have not been met. The Plan says that the enrollee could receive care in another setting. 
 
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 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 lumbar spinal surgery. The enrollee's 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 enrollee 
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 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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need 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.  
 
 You are medically stable after pulmonary embolism and do not need physical medicine and rehabilitation 
physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. There are no rehab nursing needs identified or documented 
in the record. At the current functional, you do not need IRF level of therapies, and your rehab needs can be 
met in lower setting. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (CPT 
code A4595) provided on November 27, 2021. 
 
You asked the Plan to pay for the DME. You say that the DME is medically necessary. The Plan denied your 
request. The Plan says experimental or investigational services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the DME. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found although the device may be a solution for individuals suffering from back pain, research studies 
have not been able to produce consistent results. The lack of strong evidence in support of transcutaneous 
electrical nerve stimulation (TENS) may explain why, in 2012, the Centers for Medicare & Medicaid Services (CMS), announced that Medicare benefits would no longer cover TENS treatments for chronic lower back 
pain, stating that it is not a reasonable and necessary treatment for this condition. The review has determined 
that the item/service at issue in this case is not medically reasonable or 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pay for the electrical stimulator supplies, 2 lead, per month (CPT code A4595) provided on November 27, 
2021.