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 LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating medical necessity for LTACH services. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where she is currently receiving care. 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 health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF 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 IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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.  
  
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
January 25, 2022, to January 31, 2022. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the services were 
not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that prior authorization is required for skilled nursing facility care services. 
 
The SNF services in question were not billed with the approved PDPM code. The Plan did not pre-approve 
PDPM code KDXK1 for SNF services. We found no exception that would require the Plan to pay for these 
services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) 
services provided from January 25, 2022, to January 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan provided on February 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the duplex scan. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the service was provided out-of-network and was not approved in advance. 
 
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 the duplex scan provided on February 10, 2022, by an out-of-network (OON) 
provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home COVID-19 tests purchased on January 16, 2022. 
 
You asked the Plan to pay for the home COVID-19 tests. You say that you believe this denial should be 
overturned. The Plan denied your request. The Plan says the enrollee purchased these at-home COVID-19 tests 
prior to when the benefit went into effect on February 1, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the home 
COVID-19 tests is an OTC item. However, the Plan offers a supplemental benefit for over-the-counter home 
COVID-19 tests purchased after February 1, 2022. These tests were purchased on January 16, 2022, which is 
before this benefit went into effect. Therefore, we decided that the Plan does not have to pay for the home 
COVID-19 tests purchased on January 16, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter COVID-19 tests purchased from 
December 27, 2021 to January 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for over-the-counter items. The 
services at issue are over-the-counter items. Therefore, we decided that the Plan does not have to pay for the 
over-the-counter COVID-19 tests purchased from December 27, 2021 to January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care provided on February 5, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent observation care. You say that your physicians are hospital based and 
your providers rely on the facility to obtain the proper authorizations. The Plan denied your request. The Plan 
says services from non-participating providers are not covered under open access unless preauthorized. 
 
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 subsequent observation care provided on February 
5, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare coverage 
criteria. 
 
The Plan follows Medicare rules. 
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that in this case, although 
the enrollee has a history of chronic low back pain, there is no documentation of the enrollee having tried and 
failed all prior conservative treatments including physical therapy. The review has determined that the requested facet joint injections do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on November 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that bilateral surgeries are identified by the presence on the 
claim form or electronic submission of the -50 modifier. 
 
We looked at the file and Medicare rules. The file shows that billed procedure code 50390 was not billed with 
the required -50 modifier. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services 
rendered on November 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on February 14, 2022. 
 
You asked the Plan to pay for an emergency department visit. You say that your facility has been granted 
temporary Medicare billing privileges effective November 24, 2020. The Plan denied your request. The Plan 
says that Medicare does not cover services that are not performed by a Medicare-certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation to support their denial. 
Therefore, we decided that the Plan has to pay for an emergency department visit provided on  
February 14, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis for the enrollee. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show recent injury or surgery. 
 
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 pre-approve the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding exam findings of instability of the right knee. There 
is documentation of a knee brace that she doesnt use. Documentation does not corroborate a recent injury or 
any recent surgeries. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the records do not corroborate any knee 
instability on exam or any recent injury or surgery. 
 
 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a knee orthosis for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says adequate and necessary intensive rehabilitation in the inpatient rehabilitation 
facility are being received. 
 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the clinical 
documentation states that the patient continues to require intense rehab and close physician supervision. 
Although the enrollee would clearly benefit from daily skilled nursing and therapy services from a practical 
matter intense rehab and close physician oversight would not be available in a skilled nursing 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and associated 
accessory (E0673). 
 
You asked the Plan to pay for a pneumatic compression device and accessory. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says this device is not 
covered by Medicare or the Plan. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and associated accessory (E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on January 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the special 
anesthesia service rendered on January 21, 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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. 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 weakness and falling. 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, in 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. 
 
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 pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that a portable oxygen concentrator 
is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been satisfied. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Specifically, it is being requested for future 
travel out of the country. Although this item may be helpful, neither Medicare nor the Plan covers equipment 
for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen 
concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transversus abdominis plane services coded 64488 provided 
on April 28, 2021. 
 
You asked the Plan to pay for transversus abdominis plane services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services provided were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that more than one unit of CPT code 64488 is not supported in the medical record. Specifically, the 
documentation shows that this procedure is designated as bilateral. This service was billed with multiple units. 
Procedures designated as bilateral should not be billed with multiple units. Based on this information, we 
decided that Medicare rules for coverage of transversus abdominis plane services have not been met. Therefore, 
we decided that the Plan does not have to pay for transversus abdominis plane services coded 64488 provided 
on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on November 10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Surgical Pathology Procedures provided on August 13, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Surgical Pathology Procedures. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services were not urgent or emergent. 
 
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 Surgical Pathology 
Procedures provided on August 13, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing rendered on September 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed 
adjacent to the CPT code for GeneSight testing. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX 
Z-Code. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing rendered on 
September 15, 2021.