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

 
We decided that the Plan does not have to pay for SNF care provided from July 4, 2022, to August 2, 2022. 
 You asked the Plan to pay for SNF care. You say that you are requesting reconsideration of the denial for 
payment of SNF care. The Plan denied your request. The Plan says that the enrollee no longer had skilled 
nursing facility needs. 
 
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 pay for 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 that the enrollee had reached her rehabilitation with occupational and physical 
therapy at the time of the denial. The enrollee could continue to improve with repetitive exercise. The enrollee 
also did not require continued daily skilled 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from July 4, 2022, to August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 88377-XU billed for date of service October 17, 2022. 
 
You asked the Plan to pay for code 88377-XU. You say that a modifier was added to show that the services 
were non-overlap services and should be paid separately. The Plan denied your request. The Plan says the use 
of the XU modifier for code 88377 is not supported by the medical records. As a result, 88377 is not separately 
payable from other codes billed (i.e., 81270, 81279, 81338, and 81219) 
 
The Plan follows Medicare rules. Medicare rules say that modifier XU means that the code represents an 
unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual 
components of the main service. You can find this rule at Centers for Medicare and Medicaid Services, 
Medlearn Matters MLN Fact Sheet entitled Proper Use of Modifiers 59, XE, XP, XS, and XU. 
 
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 code 88377-XU. Our reviewer says that this 
code should not be separately paid based on the medical records. Our physician reviewer found the enrollee is a 60-year-old male who received laboratory services on October 17, 2022.  You reported Current Procedural 
Terminology (CPT) 88337 Morphometric, analysis, in situ hybridization (quantitative or semi-quantitative), 
manual, per specimen; each multiplex probe stain procedure in addition to other laboratory procedures 
provided on same date of service. CPT 88337 was reported with modifier XU Unusual non-overlapping 
service, however the laboratory report does not support this procedure was non-overlapping service from other 
services reported, and therefore cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 88377-XU have not been met. Therefore, we decided that the Plan does 
not have to pay for code 88377-XU billed for date of service October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277) and physician attendance and supervision of hyperbaric oxygen therapy, per 
session (99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the enrollee could not undergo 
amputation without treatments. The Plan denied your request. The Plan says the request is not medically 
necessary because records show the enrollee does not have a compromised skin graft. There is a surgical 
wound that required closure. There is no documentation of absence of measurable signs of healing for at least 
30 days. There is no documentation of acute arterial insufficiency. 
 
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 hyperbaric oxygen therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that the enrollee has a history of peripheral artery 
disease, and underwent angioplasty in December of 2022, of the right femoral and popliteal artery. He has a 
history of left BKA for gangrene. He had previous hyperbaric oxygen therapy for treatment of a wound on the 
second toe of the right foot. He has chronic osteomyelitis of the right ankle and foot. He noted a new area of 
gangrene on his third toe in February 2023. On March 27, 2023, it was noted that his right 3rd toe had a 
Wagner 3 grade 3 diabetic non healing ulcer. This required partial digit surgical amputation of the third toe on 
March 27, 2023. In this case, the enrollee does not have a compromised skin graft. There is a surgical wound 
that required closure. There is no documentation of absence of measurable signs of healing for at least 30 days. 
There is no documentation of acute arterial insufficiency. The review has determined that the enrollee does not 
meet criteria for approval of HBOT. HBOT is not medically necessary 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 hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute interval 
(G0277) and physician attendance and supervision of hyperbaric oxygen therapy, per session (99183).
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 LTACH services would be beneficial for 
the enrollee given their good progress and expected recovery. This level of care would give them the medical 
care needed. The Plan denied your request. The Plan says the services the enrollee needs could be provided in 
another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient 
setting or home 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. 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 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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 is medically stable and ready for discharge from the hospital. She has no 
complex wound care, parental medications, or nutrition given by feeding tube. She has no skilled nursing needs 
and does not require skilled nursing on a daily basis. She is near her baseline level of function and does not 
require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary 
services on an inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 SNF admission is medically necessary. The Plan 
denied your request. The Plan says SNF admission is not medically necessary. 
 
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 not 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 doctor says that the enrollee is not willing or able to participate in daily skilled 
therapy and is functioning near her prior level. 
 
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 pre-approve an implantable loop recorder (ILR) device (33285). 
 
You asked the Plan to pre-approve an ILR device. You say that the provider submitted medical documentation 
to support the request for an implantable loop recorder device. The Plan denied your request. The Plan says the 
requested use here is for long term monitoring for potential atrial fibrillation without a formal diagnosis of 
stroke. Criteria for an ILR is not met. 
 
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 an ILR device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had no history of atrial fibrillation, nor were any significant cardiac arrhythmias 
noted on ECG monitoring. A recent randomized clinical trial found that continuous monitoring for atrial 
fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) was 
not superior to usual care in reducing stroke or systemic embolism among enrollees at high risk of stroke but 
without a known prior history of atrial fibrillation. At this time, insertion of an ILR would not be considered 
medically appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR) device (33285).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 8, 2022, to 
February 11, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that it was not medically necessary to admit this 
patient. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented with an intentional overdose. Serial laboratory monitoring was 
advised. Physical monitoring by a 1:1 sitter was warranted.  While the enrollees Dilantin levels peaked 
without incident, the enrollee remained suicidal and agitated. An inpatient level of care was medically 
necessary and reasonable, preceding the ultimate disposition to psychiatric 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 8, 2022, to February 11, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99213) rendered on 
September 6, 2022. 
 You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says Current Procedural Terminology (CPT) code 99213-25, 24 remains not supported, and cannot be 
separately reimbursed. 
 
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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
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 the visit. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the records describe the reason for 
this visit as for post-operative wound care and follow-up. Therefore, modifier 25 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit (procedure code 99213) rendered on September 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve TTE. You say that this test is medically necessary. The Plan denied your 
request. The Plan says repeat TTE is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that TTE is covered when medically necessary for the 
evaluation of derangements of valvular, myocardial and pericardial structure and function. 
 
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 TTE. Our reviewer says that the 
requested TTE is not medically necessary. Our physician reviewer found the documentation at this time would 
not point to a change in status that would support the medical necessity of a repeat TTE. Clinical guidelines do 
not support repeating a TTE with no intervening change in clinical cardiac status or new signs, symptoms or 
physical findings. In summary, there is no supportive evidence for the medical necessity of repeat TTE in this 
this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transthoracic echocardiography (TTE).
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 services are medically necessary. The Plan 
denied your request. The Plan says the medical records provided do not show that you need daily skilled 
nursing or skilled therapy needs. 
 
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 you are at a functional level which does not require daily skilled therapy to improve 
of maintain your condition. You can improve your condition with repetitive exercises. You do have custodial 
care needs, but there are no daily skilled nursing needs. 
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from November 23, 
2022, to December 22, 2022. 
 
You asked the Plan to pay for the SNF services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that the patient no longer had SNF needs on the dates of service in 
question. 
 
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 services in dispute are SNF services.  The only medical records 
that the Plan supplied in this case are a few pages of records from the patient's hospitalization.  There are zero 
records provided from the SNF itself.  According to the case file, the SNF itself is a contract facility with the 
Plan.  This means that the Plan is obligated to obtain the needed records to determine if the services were 
necessary.  By failing to provide any records from the SNF, the Plan has not shown that its denial is correct. 
Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided from 
November 23, 2022, to December 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services denied with code G rendered from 
January 8, 2022, to January 19, 2022. 
 You asked the Plan to pay for the services. You say that you submitted supporting documentation for 
reconsideration. The Plan denied your request. The Plan says several items/services initially denied due to not 
having an itemized bill have now been identified as routine items and services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the denied charges for $1,541.65 
and medical record submitted were reviewed, and it does not meet criteria. The charges for $1,541.65 denied 
correctly as these are considered routine supplies/services and therefore would not be covered separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services denied with code G rendered from January 8, 2022, to January 19, 
2022.