Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example, a skilled nursing
facility, home with home health services, or home with outpatient therapy.
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 based on the medical records provided, the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. Your medical conditions are stable on outpatient medications with no issues that require a
physician's evaluation three or more times per week. You do not require an intensive inpatient rehabilitation
therapy program. You are walking household distances with contact guard assistance and is contact guard assist
for transfers. There is no documentation that the enrollee requires the intensive rehabilitation therapy program
provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level or in the home with
home health services appears to be 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
October 19, 2021. 
 
You asked the Plan to pay for CGP testing. You say that the enrollee's treating physician ordered this testing to 
determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because comprehensive genomic profile testing 
must be billed with 1 unit only of code 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with code 81479 for 
date of service October 19, 2021.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of CGP testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
October 19, 2021.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Life Vest provided by a network provided from April 2, 2021, to August 8, 2021.
You asked the Plan to waive the coinsurance for the Life Vest. You say that the enrollee was unaware of a monthly copayment for the Life Vest. You say the enrollee was not coherent enough to agree to the Life Vest. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 10% coinsurance for all other Medicare-covered durable medical equipment. The enrollee has been asked to pay $293.15 which is 10% of the allowed amount for the Life Vest on each date of service. The allowed amount is $2,931.45. ($2,931.45 x 10% = $293.15). ($293.15 x 5 dates of service = $1,465.74). The Life Vest falls within the "Durable medical equipment (DME) and related supplies" benefit category.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Life Vest provided by a network provided from April 2, 2021, to August 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99214) provided from September 23, 2021, through October 7, 2021, by a provider who has opted-out of Medicare.
You asked the Plan to pay for the office visits. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says payment cannot be made to a provider who has opted-out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visits (99214) provided from September 23, 2021, through October 7, 2021, by a provider who has opted-out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (64448, 64446) provided July 24, 2021.
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan denied your request. The Plan says the code billed is included in the primary procedure and 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 codes 64448 and 64446 are not supported in the medical record. Specifically, these codes are included in CPT 01480. Records showing this was a separate and distinct service were not included. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (64448, 64446) provided July 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 27, 2021. 
 
You asked the Plan to pay for the services provided. You say that the lab services were needed. The Plan 
denied your request. The Plan says there is no referral/authorization on file. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copay per visit for labs.  
 
You have been asked to pay for labs services provided. The services fall within the outpatient diagnostic tests 
benefit category. The Plan contract shows that an authorization is required for outpatient diagnostic tests. There 
is no indication that a referral or authorization was provided. This means that you are responsible for the cost of 
services. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 
27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 01120 and 99100 provided on 
April 19, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that this claim should be reprocessed. The Plan 
denied your request. The Plan says this is a duplicate claim. 
 
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 looked at the file and Medicare rules. In this case, the documentation supports that this claim has 
previously paid and this is a duplicate. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded 01120 and 99100 provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 22, 2021. 
 
You asked the Plan to pay for the services provided. You say that these are billable and payable codes. The 
Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 
 We looked at the file and the rules. We find that CPT codes 84155 and 82784 were billed with modifier 26. 
Because the professional/technical component does not apply for these codes, the services are not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of the services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional medial branch blocks. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request exceeds the number of injections allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The file shows that 2 levels of medial branch blocks were requested. 
The Plan has agreed to pre-approve 1 level. The rules say that no more than 4 diagnostic joint session are 
covered per rolling 12 months. You previously received 3 medial branch blocks on July 16, 2021.  Based on this information, we decided that Medicare rules for coverage of the requested services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve additional medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (86891, P9022, 99191, 99190) provided September 21, 2021.
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. We find that CPT codes 86891, P9022, 99191, & 99190 are not supported in the medical record. Specifically, the record shows the enrollee was an inpatient at the time these services were provided. Payment is included in payment to the facility. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (86891, P9022, 99191, 99190) provided September 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study for the enrollee. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of an Apnea-Hypopnea Index (AHI) or Respiratory 
Disturbance Index (RDI) establishing a diagnosis of obstructive sleep apnea.  
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 study. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee reports a history of obstructive sleep apnea (OSA) and is requesting continuous positive 
airway pressure (CPAP). However, the medical records do not mention any sleep symptoms other than 
insomnia. There is no mention of excessive daytime sleepiness, snoring, witnessed apneas, or other symptoms 
associated with OSA. There is no Epworth score. The medical records do not provide any justification for the 
sleep study. 
 
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 study have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sleep study for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular gene testing provided on April 
8, 2021. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was a covered service. 
The Plan denied your request. The Plan says the screening panel does not meet coverage criteria. 
 
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. 
 
We looked at the file and the rules. In this case, the records do not show that the testing ordered was part of the 
enrollees treatment plan. There is no indication that the test was ordered for a specific medical problem. The 
records do not show that the results of testing will impact clinical management. Medicare does not cover this 
testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary 
cardiovascular gene testing provided on April 8, 2021.
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 (A4595), 
provided on November 12, 2021. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is not covered for the members diagnosis. 
 
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 electrical stimulator supplies. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the patient does not have documented muscle wasting or a documented 
covered diagnosis for TENS unit and the TENS is not covered for degenerative back pain. 
 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 electrical stimulator supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595), provided on 
November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral facet joint radiofrequency ablation (RFA) 
services. 
 
You asked the Plan to pre-approve facet joint services. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint services are subject to the criteria listed 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 facet joint services. Our reviewer says 
that the requested services are not medically reasonable and necessary. Our physician reviewer found In this 
case, the enrollee has non-axial left shoulder pain and left upper extremity radicular pain which is inconsistent 
with facet-mediated cervical pain.  In addition, the September 28, 2021, non- contrast cervical spine magnetic 
resonance imaging scan shows radiographic evidence of several non-facet pain generators (degenerative central 
spinal stenosis and multilevel neuroforaminal stenosis worse at the C6-7 level), also inconsistent with facet-
mediated cervical pain. The most recent prior ineffective thermal radiofrequency cervical facet medial branch 
ablation at the same anatomic levels on May 13, 2021, did not satisfy the following required criteria:  
"minimum consistent at least 50% improvement in pain for at least six (6) months or at least 50% consistent 
improvement in the ability to perform previously painful movements and ADLs as compared to baseline 
measurement using the same scale."  The review has determined that the documentation does not support that 
the coverage criteria for facet joint services have been met. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bilateral facet joint radiofrequency ablation (RFA) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from June 28, 2021, to July 9, 2021. 
 You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says there was 
no daily skilled nurse or therapist need. 
 
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 the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee did not require skilled 
nursing or therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from June 28, 2021, to July 9, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from July 15, 2017, 
through July 20, 2017, billed with J96.01. 
 You asked the Plan to pay for the inpatient hospital care as billed. You say that the medical records support the 
inpatient hospital care as originally billed. The Plan denied your request. The Plan says the documentation does 
not support the billed secondary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, J96.01, defined as acute 
respiratory failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply 
the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital care as billed. Our reviewer says that the documentation does not support the billed secondary 
diagnosis code J96.01, defined as acute respiratory failure with hypoxia. Our physician reviewer found that the 
reviewed documentation indicates that the enrollee was a then, 86-year-old enrollee who presented to the 
emergency department on July 14, 2017, with aspiration pneumonia and hypoxia. Initial oxygen saturation was 
86% on room air. There was no evidence for respiratory distress. There was no documentation of increased 
work of breathing. There was no documentation of CO2 retention. The enrollee was treated with intravenous 
antibiotics and supplemental oxygen by nasal cannula--maximal flow was 4L/min. The enrollee was weaned to 
room air at discharge. There was no documentation of acute respiratory failure with hypoxia. The review has 
determined that the documentation did not support the provider billing the secondary diagnosis code J96.01 - 
acute respiratory failure with hypoxia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from July 15, 2017, through July 20, 2017, billed with J96.01.