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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial and would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says the request 
for an LTACH admission 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 that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary at this time as 
the enrollee is not yet stable for transfer and it would not be clinically advantageous. Completion of treatment 
at the current facility 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve frozen meals twice per day for two weeks. 
 
You asked the Plan to pre-approve frozen meals twice per day for two weeks. You say that you recently had 
surgery and cannot cook for yourself. You also say that you live with your husband, and he cannot cook. The 
Plan denied your request. The Plan says the documentation indicates that you have been recently discharged 
from an acute hospital admission, and have already received the post discharge meal benefit on December 1, 
2022. The Plan also says it is not reasonable nor necessary to cover this request at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that all benefits that are part of the MA plan must 
satisfy the guidelines listed in the Medicare rules section of this letter.  
 
We looked at the file and Medicare rules. The Evidence of Coverage clearly states that after a discharge from 
an acute inpatient hospital stay or skilled nursing facility, you may be eligible to receive 14 nutritious frozen 
meals delivered to your home. The record shows that you were discharged from an acute inpatient hospital stay 
and had received your meal benefit on December 1, 2022. Based on this information, we decided that Medicare 
rules for coverage of frozen meals twice per day for two weeks have not been met. Therefore, we decided that 
the Plan does not have to pre-approve frozen meals twice per day for two weeks.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital admission from June 2, 2022, through June 6, 
2022. 
 
You asked the Plan to pay for the inpatient hospital admission. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that the services were not authorized. 
 
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 rules say that an emergency exists based on a prudent layperson standard, not a retrospective 
medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson 
with an average knowledge of medicine would reasonably expect the absence of immediate medical attention 
would result in serious jeopardy to their health. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The enrollee was found to be suffering from a slowed heart rate along with chest 
pain and nausea. This would meet prudent layperson criteria and authorization would not be required. We 
decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an 
average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously 
jeopardize their health in this case. Therefore, we decided that the Plan has to pay for the inpatient hospital 
admission from June 2, 2022, through June 6, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 and presumptive drug 
testing billed with code 80307 for date(s) of service August 10, 2022. 
 
You asked the Plan to pay for codes 83789 and 80307. You say that these services are medically necessary and 
should be paid. The Plan denied your request. The Plan says code 83789 is not separately payable, and code 
80307 is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. The rules also say that 
providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. In addition, we find that CPT code 80307 is not supported in the medical record. 
Specifically, no results of a presumptive drug screening were provided for review. Therefore, we decided that 
the Plan does not have to pay for validity testing billed with code 83789 and presumptive drug testing billed 
with code 80307 for date(s) of service August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 02, 2021, 
through November 12, 2021, and billed with diagnosis code G93.41. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis code G93.41 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of G93.41. 
 
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 G93.41 (Metabolic 
encephalopathy). 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 
services at the DRG originally billed. Our reviewer says that to validate the secondary diagnosis G93.41 
(Metabolic encephalopathy), the following must be submitted: documentation of the diagnosis by the 
physician, documentation that supports a change in mental status which is beyond baseline, diagnostic work up 
must be evident, and documentation of a potential cause. The member was noted to have underlying dementia. 
Per the members history and physical, the member was alert and pleasantly demented. The documented 
alteration in mental status was not significantly worse than the members baseline at the time of admission or 
during hospitalization. The member was pleasantly confused. There was insufficient objective clinical evidence 
to validate the diagnosis. With that being said, diagnosis code G93.41 (Metabolic encephalopathy) is 
inappropriate as a secondary diagnosis. Our physician reviewer found the member was noted to have 
underlying dementia, per the members history and physical the member was alert and pleasantly demented. The 
documented alteration in mental status was not significantly worse than the members baseline at the time of 
admission or during hospitalization, the member was pleasantly confused. There was no clinical or laboratory 
evidence of metabolic encephalopathy and therefore, secondary diagnosis G93.41 (Metabolic encephalopathy) 
is not appropriate.  
 
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 on November 02, 2021, through November 12, 2021, and billed with 
diagnosis code G93.41.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis Emulsion. 
 
You asked the Plan to pre-approve Restasis Emulsion. The Plan denied your request. The Plan says Restasis 
Emulsion does not meet the Medicare criteria to be covered under the enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis Emulsion.  
 
  Benefits for Restasis Emulsion may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
its safety and effectiveness. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the critical care services (99291) provided on July 5, 2022. 
 
You asked the Plan to pay for the critical care services. You say that the providers are practicing under 
different specialties, and you would like this claim to be reprocessed for payment. The Plan denied your 
request. The Plan says that payment for this service is included in the fee for the procedure. 
 
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. The records do not support that payment for this service is included in the fee for 
the procedure. The documentation does not show that any other codes/services were billed with this critical 
care service on July 5, 2022. This means that the Plan has not provided a valid reason for denying payment of 
the critical care services. It is the burden of the Health Plan to substantiate their denial with evidence. In this 
case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan 
has to pay for the critical care services (99291) provided on July 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83520, 82656) provided on May 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
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 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 lab 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 lab services (83520, 82656) provided on May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cancer testing panel provided on August 4, 
2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says only a single 
code should be reported. 
 
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 the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the hereditary cancer testing panel provided on August 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator, rental (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that please see attached request 
to certify the enrollee for on-going use of equipment. The Plan denied your request. The Plan says the 
additional medical records did not show evidence of meeting the plan criteria because payments have been 
made for 36 months of rental for the current oxygen equipment. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
The file shows that the enrollee has E1390. E1390 serves the same purpose as the portable oxygen 
concentrator. The records show that 36 payments have already been provided for E1390 and the requested 
E1392 would be considered an upgrade. Per the LCA upgrades do not start a new rental period. Therefore, we 
decided that the Plan does not have to pre-approve the portable oxygen concentrator, rental (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care provided on June 14, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for initial observation care. You say that you want the Plan to pay for the service. 
The Plan denied your request. The Plan says services received out-of-network are 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 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 initial observation care provided on June 14, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the annual wellness visit (AWV) (G0439) 
provided on October 6, 2021. 
 
You asked the Plan to reimburse you for the wellness visit. You say that you would like to be reimbursed. You 
say that this has been your provider for 20 years. You also say that this provider only sees patients once per 
week. The Plan denied your request. The Plan says the benefit for this service has been exhausted prior to the 
date of service in this case. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to reimburse you for the annual wellness visit (AWV) 
(G0439) provided on October 6, 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 an LTACH is the most appropriate level 
of care for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient care and is currently unstable for transfer to an LTACH. 
 
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 that the enrollee appears to be improving with treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary at this time as it would not 
be clinically advantageous. Completion of treatment at the current facility 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: 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 enrollee meets Medicare criteria for 
LTACH, and the enrollee's needs cannot be met in the current facility or a SNF. The Plan denied your request. 
The Plan says the LTACH is not medically necessary, and the enrollee's needs are being met in the current 
facility. 
 
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, the enrollee patient is currently undergoing treatment at 
an acute care hospital (ACH) for acute-on-chronic respiratory failure. The enrollee is not intubated/ 
ventilated. There is no evidence that the enrollee requires services that are not currently available at the ACH. 
 
 
 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.