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

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 12, 2020 to December 28, 2020. 
 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the DRG was updated in this case. 
 
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 DRG 853 (INFECTIOUS AND PARASITIC 
DISEASES WITH O.R. PROCEDURE WITH MCC). 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 the services at issue in this case were not supported by the medical 
records. Our physician reviewer found the documentation from throughout the hospital stay does not support 
sepsis as a primary diagnosis.  
 
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 inpatient hospital services provided to the enrollee from December 12, 2020 to December 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve authorization of continued stay in a skilled nursing 
facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that the enrollee needs more time for rehabilitation. 
The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 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 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services or skilled therapy services after 3/14/22. The specialized skill, knowledge and judgment of a 
skilled professional nurse and qualified therapist are not required to safely and effectively provide medically 
necessary and reasonable treatment. The documentation does not support that it is medically reasonable and 
necessary to provide skilled services after 3/14/22 on a "daily basis" on 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve authorization of continued stay in a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of CPT 77002 provided to the enrollee on 
March 30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an inappropriate amount of units was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77002 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. 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 an additional unit of 
CPT 77002 provided to the enrollee on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service March 31, 
2021. 
 
You asked the Plan to pay for procedure code 99291. You say that this code was billed correctly and supported 
by the medical records. The Plan denied your request. The Plan says the medical records do not support 
payment of this code. 
 
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 99291 is services of a physician providing full attention 
to a critically ill or critically injured patient from 30-74 minutes on a given date. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, billing of this code requires 
that the medical documentation show that the total time with the patient to provide critical care services is 
between 30 and 74 minutes.  The medical record provided does not state the number of minutes spent with the 
patient, so this code cannot be verified. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for date of service 
March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with seat attachment. 
 
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 a walker is covered when specific criteria are 
met. 
 
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 do 
not show that the enrollee has a mobility limitation that significantly impairs her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) in the home. The records do not show that she is 
safely able to use the walker. She was approved for a walker in 2020 ad it is not clear why she requires and 
additional walker. The services are 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 a walker with seat attachment.
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 this is necessary for the enrollee to fully recover. The 
Plan denied your request. The Plan says the enrollee can be treated at a lower level of care. 
 
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 there are no acute rehabilitation or skilled nursing needs identified or 
documented in the record. The enrollee is medically stable with complex course so far and does not need 
physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. At the current functional level, the enrollee does not need or will 
tolerate intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. The enrollee will not be able to make a significant 
functional improvement in a predicted and reasonable period of time in an IRF as required by CMS guidelines. 
IRF admission is not medically necessary based on lack of medical complexity and lack of acute rehab nursing 
needs and low tolerance to activity. Her rehab needs can be met at a lower intensity 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services received from June 7, 2021, to August 
25, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services were rendered by a provider not certified with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no 
exception that would require the plan to pay for these items/services. 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 home health services received from June 7, 2021, to August 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve authorization of a skilled nursing facility (SNF) 
admission. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 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 
daily skilled services are not necessary. Our physician reviewer found you do not require the specialized skill, 
knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary 
and reasonable treatment. The documentation does not support that it is medically reasonable and necessary to 
provide these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" 
on 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve authorization of a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for the office visit you had with a urologist and the 
cystoscopy procedure you had on July 6, 2021. 
 
You asked the Plan to waive the cost sharing for the urology visit and the cystoscopy procedure. You say that 
you do not believe you should be responsible for these copayments. The Plan denied your request. The Plan 
says that you were charged these copayments correctly. 
 
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, your Evidence of Coverage says that applicable copayments are 
listed in your Benefit Highlights document.  The Plan has failed to provide a copy of this Benefits Highlights 
document in the case file it submitted to us.  We reached out to the Plan to have them provide this document to 
us, but the Plan has not responded to our request.  Without this document, we cannot tell if the Plans 
application of cost sharing is correct. The burden is on the Plan to prove that its assessment of cost sharing was 
appropriate, and they have not done so. Therefore, we decided that the Plan has to waive the cost sharing for 
the office visit you had with a urologist and the cystoscopy procedure you had on July 6, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller for use with an approved 
power wheelchair. 
 
You asked the Plan to pre-approve the controller. You say that this is medically necessary. The Plan denied 
your request. The Plan says everything was approved but there is no need for control of power seating systems 
from the main controller; individual switches can be used. 
 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 controller. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that it is medically necessary to control the power options 
through the joystick. Any power options can be controlled by their own switches. 
 
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 controller have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the expandable controller for use with an approved power wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested continued SNF care does not meet 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing. The specialized skill, knowledge and judgment of a skilled professional nurse are not required to 
safely and effectively provide medically necessary and reasonable treatment. The documentation does not 
support that it is medically reasonable and necessary to provide skilled therapy services on a "daily basis" on an 
inpatient basis, in a skilled nursing facility setting. As a practical matter, the enrollee does not require necessary 
services on 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
September 10, 2020, to September 15, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG was changed from 286 to 287.  
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 DRG 286 (CIRCULATORY DISORDERS 
EXCEPT AMI, WITH CARDIAC CATETERIZATION WITH MCC). 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 the services at issue in this case were not 
supported by the medical records. Our physician reviewer found the documentation does not support the 
criteria for cardiogenic shock, condition of the heart inability to pump adequate amount of blood. The 
documentation does not support clinical manifestations of hypotension, hypoperfusion, abnormal mental status, 
cold clammy skin, and evidence of metabolic acidosis, therefore this diagnosis cannot be validated. The 
documentation does not support the level of service billed; in this case a query would be made before reporting.  
 
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 inpatient hospital services provided to the enrollee from September 10, 2020, to September 15, 2020.
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have billed these services correctly. The Plan 
denied your request. The Plan says you billed with an incorrect Place of Service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for lab services provided on April 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
September 4, 2021, to September 21, 2021. 
 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 the enrollee did not meet criteria for coverage of these SNF services. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the patient's condition did not change 
between September 4, 2021, and September 21, 2021.  The patient did not require skilled nursing or skilled 
therapy services on these dates.  The doctor also found that the patient did not require these services on a daily 
basis nor were services required on an inpatient basis. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from September 4, 2021, to September 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiology services provided on August 5, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the cardiology services. You say that you have provided medical records to 
support payment of these services. The Plan denied your request. The Plan says unauthorized, non-plan care is 
not covered. 
 
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 provider in this case is not a network provider with the Plan. 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 cardiology services provided on August 5, 2021, 
by an out-of-network (OON) provider.