Persius/hicric huggingface dataset:
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 you were in the intensive care unit (ICU) 
and were sedated for 23 days with intubation due to crashing at least twice, and you are currently unable to eat. 
You also say that you currently have a bowel tube and are on dialysis, and currently unable to walk. You also 
say that due to the current condition you are unable to be moved to skilled nursing, but still need acute care. 
The Plan denied your request. The Plan says based on Medicare guidelines and the information they have about 
your condition; you don't meet all the requirements. 
 
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 the patient appears to be stable and improving and requires only short-term additional 
acute care hospital services that can be safely administered at the current facility until more appropriate for a 
lower level of care. Our physician reviewer also found the patient does not require services at the LTACH that 
are not already available at the current facility. Our physician reviewer also found that a transfer to LTACH is not medically necessary as it would not be clinically advantageous at this time, and 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that you need SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 you are appealing with supporting 
records. The Plan denied your request. The Plan says based on Medicare guidelines and the information they 
have about the enrollee's condition; the enrollee does not meet all the requirements. 
 
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 the patient appears to be more stable and improving and requires only short-term 
additional acute care hospital services that can safely be administered at the current facility until more 
appropriate for a lower level of care. Our physician reviewer also found that the patient does not require 
services at the LTACH that are not already available at the current facility. Our physician reviewer also found 
that a transfer to LTACH is not medically necessary as it would not be clinically advantageous at this time, and 
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says rules for LTACH care have 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 enrollee is receiving appropriate care at the present acute care hospital. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 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 needs to be in a LTACH. 
The Plan denied your request. The Plan says rules for LTACH care have 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 enrollee is receiving appropriate care at the present acute care hospital. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for supply allowance used with a therapeutic CGM device (K0553) 
provided December 20, 2021. 
 
You asked the Plan to pay for the supply allowance. You say that your decision to dispense supplies was reliant 
on an approved authorization. you would not have dispensed the product without receiving the verification 
establishing coverage and the approved authorization that was required. The Plan denied your request. The Plan 
says that the records do not support the billed service. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the supply allowance. Our reviewer says that 
the enrollee meets the Medicare medical necessity criteria for the CGM supply. Our physician reviewer found 
although the enrollee does not now have a formal regimen where he adjusts the doses at each meal, based on 
the bg level while on the u500 regimen, it does appear as if the diet and  insulin doses are adjusted based on the 
CGM data. This is documented by the provider in the note. Hence criteria are met for the CGM supplies. 
 
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 supply allowance have been met. Therefore, we decided that the Plan has to 
pay for supply allowance used with a therapeutic CGM device (K0553) provided December 20, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed without the appropriate modifier. 
 
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 billed CPT codes are not supported in the medical record. Specifically, these codes have a 
PC/TC indicator of 1. The services were billed with place of service 22. As the professional interpretation was 
furnished in same payment locality as the technical component, the professional interpretation must be billed 
with modifier -26. 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 the services provided on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral device/appliance provided on September 20, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for oral device/appliance. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says payment is not allowed for this service because we 
didnt receive a PCP referral to review and approve. 
 
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 oral device/appliance provided on September 20, 
2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the records provided 
support the need for inpatient psychiatric care. The Plan denied your request. The Plan says that the enrollee 
could be treated at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on June 25, 2022, with Major Neurocognitive 
Disorder, Most Likely Due to Alzheimer's Disease with Behavioral Disturbance. Based upon review the 
records provided it was expected this enrollee would improve in a reasonable period of time beyond the dates 
in question as he continued to show some aggression, hence the medication adjusted. It did appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question, as the enrollee had abnormal behaviors. It did appear that the 
services for the dates in question were reasonably expected or medically necessary to improve the patients 
condition or for the purpose of diagnosis. The enrollee could not have been treated in a lesser restrictive setting, 
as the enrollee was showing acute threats to safety and was having medication adjusted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric hospital 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on February 
15, 2022. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that this fee is in addition to the 
primary anesthesia procedure and the attached description documents the qualifying circumstances that enable 
this code to be paid. You say that is separately payable based on guidelines and the code should be reviewed 
for appropriate reimbursement. The Plan denied your request. The Plan says bundled services are not eligible 
for separate payment. 
 
  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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on September 15, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that these hearing aids were medically necessary for 
your hearing loss. The Plan denied your request. The Plan says although there is a supplemental benefit for 
hearing aids, these hearing aids must be purchased through the Plan's hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from the Plans certified hearing aid vendor. 
 
We looked at this the file and the Plan's rules. In this case, there is no evidence the Plans certified hearing aid 
vendor was contacted prior to when these hearing aids were purchased.  Based on this information, we decided 
that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan 
does not have to pay for the hearing aids purchased on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on 
February 24, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you went for new glasses and did 
not ask for the tests that were done. You also say that only an eye exam should have been provided. The Plan 
denied your request. The Plan says the copayment of $45 was applied correctly.  
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. You are responsible for a $45 copay per visit for exams of the eye related to a medical condition. 
 
We looked at the file and the Plan's rules. The record shows that this claim was billed to the Plan with the 
diagnoses of Other Subjective Visual Disturbances, Keratoconjunct sicca, not specified as Sjogrens, bilateral, 
Age-related nuclear cataract, bilateral, and Histoplasmosis capsulati, unspecified. This eye exam was provided 
for medical conditions, and you are responsible for a $45 copayment. Based on this information, we decided 
that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does 
not have to waive the copayment for the eye exam (92004) provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on February 
14, 2022. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that this fee is in addition to the 
primary anesthesia procedure and the attached description documents the qualifying circumstances that enable 
this code to be paid. You say that is separately payable based on guidelines and the code should be reviewed 
for appropriate reimbursement. The Plan denied your request. The Plan says bundled services are not eligible 
for separate payment. 
 
  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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings identified with code 
A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered 
benefit by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
non-covered because they do not meet the statutory definition of a surgical dressing.  
 
 Although this item may be appropriate for you, it does not fall into a covered benefit category and cannot be 
paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve gradient 
compression stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81455) provided on October 20, 
2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this testing is an excluded service 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing services (81455) provided on 
October 20, 2021.