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

 
We decided that the Plan has 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 that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found although debility is not an IRF compliant diagnosis, clinical documentation is comprehensive in 
recommendation for you to receive intense, multi-disciplinary rehabilitation in an inpatient setting with an 
interdisciplinary approach to rehabilitation including in the plan by medical provider and evaluating therapists. 
There is documentation that you would be able to tolerate and significantly benefit from intense rehabilitation. 
You require two disciplines of therapy, physical therapy and occupational therapy. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have had 
massive weight loss since gastric bypass in February of 2020. The records do not establish that you have tried 
and failed conservative treatments for the complications of excessive pannus. The records do not support that 
the requested panniculectomy is reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a panniculectomy.
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 there is documentation that daily skilled 
services are required. Based on the medical records provided there is no documentation that the enrollee 
requires the services on an inpatient basis, only in a SNF setting. Continued care in the acute inpatient 
rehabilitation facility is appropriate until the enrollee is stable to transfer to a lower 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee really needs services because 
they obtained more clinical information stating that the bilevel positive airway pressure (BiPAP) machine was 
ineffective. The Plan denied your request. The Plan says the enrollee's doctor has prescribed a ventilator to help 
their breathing at various times of the day because of their lung disease; however, Medicare does not cover 
ventilators used in this way. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to chronic obstructive pulmonary disease (COPD). 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary.  This enrollee was recently hospitalized with a 
COPD exacerbation, with acute on chronic hypercarbic respiratory failure. The enrollee may benefit from 
BiPAP during sleep as an outpatient, with or without average volume-assured pressure support (AVAPS).  But Medicare does not pay for a ventilator when used as BiPAP. The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on June 19, 2021.
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 it is medically better for you to be at a SNF until 
you have your prosthetic legs. 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 there is no documentation that daily skilled 
services are required. Although records document you are very limited functionally, provided records do not 
document a significant decline in the patients functional status compared to your recent baseline to necessitate 
daily inpatient skilled therapy services. Based on the medical records provided there is no documentation that 
you require the services on an inpatient basis, only in a SNF setting. The records do not document services in 
the long-term care facility on a part time basis are not appropriate, if services are needed in the future. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are in-
network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 87150 provided on April 13, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the place of service billed is incorrect. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 87150 provided on April 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice care (Q5001, G0299, G0300) provided on January 1 
to January 16, 2022. 
 
You asked the Plan to pay for hospice care. You say that the hospice care at issue was a necessity for the 
enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospice care (Q5001, G0299, G0300) provided on January 1 
to January 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapy services (CPT code 
G0151 x 4). 
 
You asked the Plan to pre-approve the home health physical therapy services. You say that the services are 
necessary. The Plan denied your request. The Plan says the medical record does not document a clearly evident 
need for the services of a skilled physical therapist. The Plan states the enrollee has already been educated on a 
home exercise program and there is no documentation of an active or acute on chronic condition that would 
necessitate a new program. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapy 
services. Our physician reviewer found there is no documentation that further skilled therapy services are 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of 
function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or 
prevent deterioration. As of June 1, 2022, the enrollee was walking 450 feet with supervision and no assistive 
device and was independent for transfers and using a cane for stairs. Provided records do not document any 
acute or unstable medical conditions or changes in medication or treatment which would necessitate any further 
skilled therapy visits beyond what have already been approved. No medical notes from the enrollees treating 
physician are provided documenting a need for additional skilled therapy services. After twenty (20) physical 
therapy treatments, records do not support that the complexity of the enrollee's conditions are such that the 
skills of a professional therapist are required to achieve further improvement in the enrollee's symptoms or 
functional status. Further utilization of the home exercise program appears appropriate at this point. 
 
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 home health physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the home health physical therapy services (CPT code G0151 
x 4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 2, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the determination of refractive state 
(92015) provided on January 26, 2022. 
 
You asked the Plan to waive the copayment for the determination of refractive state. The Plan denied your 
request. The Plan says you received an annual routine eye exam and where you were also issued a prescription 
for your refractions. The Plan also says that according to your health plan benefit, you are covered for a routine 
eye exam once per year with $0 copay, but for eye refractions there would be a $10 copay applied. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one annual routine exam, and you are responsible for a $10 copayment for eye 
refractions. 
 
We looked at the file and the Plan's rules. During your eye exam, you received a determination of refractive 
state. Based on this information, we decided that the Plan's rules for coverage of the determination of refractive 
state have not been met. Therefore, we decided that the Plan does not have to waive the copayment for the 
determination of refractive state (92015) provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on November 29, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 drug testing provided on November 29, 2021 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on October 24, 
2021. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between 36556 and 99291. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service 
was not billed appropriately by Medicare coding regulations. 
 
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, we have confirmed that code 99291 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care, first hour (99291) provided on October 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9366) provided from January 5, 
2022, to January 6, 2022. 
 
You asked the Plan to pay for home infusion therapy. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says the code billed is not valid for Medicare purposes. 
 
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 S9366 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9366 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for home infusion therapy (S9366) provided from January 5, 2022, to January 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110) provided on October 16, 
2021. 
 You asked the Plan to pay for physical therapy. You say that these services were medically necessary and were 
billed correctly. The Plan denied your request. The Plan says these services are not supported 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 code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy services were 
being rendered. The incident-to requirements have not been met in this case. 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 pay for physical therapy services (97110) provided on October 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve these services. 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. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of prior spinal 
fusion with ongoing low back pain. MRI lumbar spine was requested to visualize fusion stability status. He has 
tried physical therapy with 50 to 75 percent improvement in symptoms and 44 percent improvement in 
Oswestry Disability Index (ODI). There is insufficient support in the records for MRI, as he is improving with 
conservative treatment and does not have clear signs of a red flag diagnosis that would warrant MRI. The 
services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.