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

 
We decided that the Plan does not have to pay for the pathology services provided on July 16, 2021. 
 
You asked the Plan to pay for the services provided. You say that the report supports payment. The Plan denied 
your request. The Plan says the service was not reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, must furnish to the 
intermediary or carrier sufficient information to determine whether payment is due. 
 
 
 We looked at the file and Medicare rules. In this case, the records provided only include a pathology report. 
There are insufficient medical records to indicate the reasoning for the testing and how it will impact clinical 
management. Based on this information, we decided that the Medicare rules for coverage have not been met.  
Therefore, we decided that the Plan does not have to pay for the pathology services provided on July 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. Despite 20 days of 
daily inpatient skilled therapy services, records document no improvement in her functional status in the skilled 
nursing facility. At this point further improvement in her functional status is not predictable in a reasonable 
timeframe to necessitate further daily inpatient skilled therapy services. Part time therapy services now appear 
appropriate based on the medical records provided. The enrollee does not require the services on an inpatient 
basis, only in a skilled nursing facility setting. Records do not document that services in the home with home 
health care or in a long-term care facility on a part time basis are not 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued 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) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee had a right clavicle fracture and 
needs physical therapy to speed up the recovery. You say that this affects the enrollee's day to day life. You say 
that the enrollee is ready for discharge from the current facility. The Plan denied your request. The Plan says 
the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee can receive the care 
needed in another setting. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires skilled nursing services. The records do not document the need for intravenous medications, 
new tube feeding, or ostomy care or daily complex wound care. The medical records do show that the enrollee 
requires skilled therapy services. However, these services are not required on a daily basis. There is no 
documentation that the enrollee requires the services on an inpatient basis, only in a SNF setting. The records 
do not document that services in the home with home health care or in a long-term care facility on a part time 
basis are not 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service February 
16, 2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 procedure code 70450-26 billed for date of service 
February 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480-26 billed for date of service February 
15, 2022. 
 You asked the Plan to pay for procedure code 70480-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70480-26 is bundled into 
payment for code 70450. 
 
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 
70480-26 is a column II code to column I code 70450. 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 procedure code 70480-26 billed for date of service 
February 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health aide visits and 3 home health physical 
therapy visits. 
 
You asked the Plan to pre-approve 2 home health aide visits and 3 home health physical therapy visits. You say 
that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 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 2 home health aide visits and 3 home 
health physical therapy visits. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the review has determined that the records do not show that skilled nursing services are 
required to effectively provide treatment, care, and/or services in order to improve your condition, or to 
establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The records 
do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in 
order to improve your level of function, or to establish/perform a maintenance program to maintain your level 
of function and/or prevent deterioration. The requested services do not meet the definition of home health aide 
services as per Sections A, B, C, D & E of Section 50.2. The home health aide services are not reasonable and 
necessary to the treatment of your illness or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 home health aide visits and 3 home health physical therapy visits have not 
been met. Therefore, we decided that the Plan does not have to pre-approve 2 home health aide visits and 3 
home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 27, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service January 27, 
2022.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is medically necessary at this time as it would 
not be clinically advantageous. Completion of treatment at the current acute care hospital is recommended. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 16, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service February 16, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient hospital services provided from 
July 21, 2021, to July 24, 2021. 
 
You asked the Plan to waive the cost share for the outpatient hospital services. You say that you are not happy 
with the inaccurate billing practices. The Plan denied your request. The Plan says the cost share was applied 
correctly 
 
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 10% of 
the total cost of the facility visit. Your cost-share is based on: the tests/services/ supplies you receive, the 
provider of the tests/services/supplies, and the setting where the tests/services/supplies are performed. 
 
 
  You have been asked to pay a total of $206.42 for the outpatient hospital services. 
 
Date of 
Service 
Service Allowed 
Amount 
Standard Cost Member Liability 
July 22, 2021 Echocardiography $25.26 10% $2.53 
July 23, 2021 Coronary Angiography  $6,219.59 10% $180.04 (less than 10% 
coinsurance) 
July 23, 2021 Sedation $12.41 10% $1.24 
July 23, 2021 Coronary Angiography $294.12 10% $22.61 (less than 10% 
coinsurance) 
TOTAL:    $206.42 
 
The outpatient hospital services fall within the Outpatient hospital services benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for outpatient hospital services provided from July 21, 2021, to July 24, 
2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has 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 that you have no daily skilled nurse or therapist 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 physician reviewer 
found you have documented new functional impairments and are documented as requiring intravenous (IV) 
fluids with close monitoring of blood pressure thus skilled nursing and therapy is medically necessary. 
Evaluating therapists and provider both recommend that skilled nursing/therapy services be completed as 
inpatient in a skilled nursing facility and from a practical matter clinical documentation supports the need for 
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 been met. The Plan must continue 
coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper 
notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has 
to pre-approve SNF care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided to the enrollee on November 19, 
2021. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test. 
 
The denied test is not a covered benefit at this time. Based on this information, we decided that Medicare rules 
for coverage of the test have not been met. Based on this information, we decided that Medicare rules for 
coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for the 
CxBladder test provided to the enrollee on November 19, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that your 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 SNF care. Our reviewer says that SNF 
care is medically reasonable and necessary for the enrollee. Clinical documentation states that you require 
skilled nursing care for continued management of blood glucose and blood pressure and that you have new 
functional deficits related to hospitalization. Evaluations by therapist recommend that you receive therapy 
sessions on an inpatient basis. Based on clinical documentation, you would benefit from daily skilled services 
on an inpatient basis in a skilled nursing facility. Our physician reviewer found that your condition meets 
Medicare criteria for SNF 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 22, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
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 the laboratory services provided on September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor ankle-foot system (L5973) 
 
You asked the Plan to pre-approve a microprocessor ankle-foot system. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the requested microprocessor 
ankle-foot system exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. The rules say that a 
microprocessor controlled ankle foot system (L5973) is covered for beneficiaries whose functional level is 3 or 
above. 
 
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 a microprocessor ankle-foot system. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 56-year-old male with past medical history of right below 
knee amputation using a K2 level prosthesis. In this case, clinical documentation states that patient is requiring 
assistive device and having difficulty negotiating steps due to current prosthesis as it is a K2 level that is meant 
for even surface ground level only. Clinical documentation states that patient requires microprocessor ankle 
foot unit due to variability in cadence and surface of ambulation. Therefore, a microprocessor K3 level 
ankle/foot prosthetic is 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 a microprocessor ankle-foot system have been met. Therefore, we decided that 
the Plan has to pre-approve a microprocessor ankle-foot system (L5973)  
 
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.