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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee is receiving acute hospital care, and acute care services have not been 
denied. The documentation does not support that the enrollee in this case requires services at the LTACH that 
are not available at the acute care hospital where he is currently receiving care. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee at this time. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on September 
16, 2021. 
 
You asked the Plan to pay for the services. You say that Medicare covers emergency services for a sudden 
illness. The Plan denied your request. The Plan says the plan does not cover this expense. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 16, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on 
September 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
January 21, 2022, through January 23, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says 
InterQual criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee is a 74-year-old male who presented to the emergency department 
with hemoglobin 6.9 drawn as outpatient. He was asymptomatic except for chronic upper abdominal pain 
related to non-healing abdominal wound from surgery for bowel perforation being managed as outpatient. He 
was noted to have normal vitals. Based on the enrollees presentation, they were stable and without acute 
distress or expectation for hospital services that would likely cross 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from January 21, 2022, through  
January 23, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the short-latency somatosensory evoked potential study (95927) 
provided on October 6, 2021. 
 
You asked the Plan to pay for the short-latency somatosensory evoked potential study. You say that you would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the 
documentation submitted does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 95927 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or 
skin sites, recording from the central nervous system; in the trunk or head. 
 
We asked our coder 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 short-latency somatosensory evoked potential study. Our 
reviewer says that CPT code 95927 meets criteria for billing and reimbursement consideration. Our reviewer 
found the procedure report describes electrical stimulation ulnar nerve, and ERBs point. Therefore, this 
procedure should be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the short-latency somatosensory evoked potential study have been met. 
Therefore, we decided that the Plan has to pay for the short-latency somatosensory evoked potential study 
(95927) provided on October 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: 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 SNF care is medically necessary. The Plan 
denied your request. The Plan says you do not meet the Medicare coverage criteria for SNF 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 services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that you do not require skilled 
nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further 
rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility. You do not have any parental medication; complex wound care or nutrition 
given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical 
problems. It is unclear from the documentation what your baseline function is, however, you have not made 
progress with inpatient therapy services. You can receive services at a lower level of care. Admission to a SNF 
for inpatient skilled rehabilitation services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
September 16, 2021 to September 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 payment of DRG 871 was not supported, and the review suggests that DRG 592 may be 
supported. 
 
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 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS 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 discharge summary indicated the admission was for acute encephalopathy. 
The limited documentation does not allow for an accurate determination of the primary diagnosis. From the 
information that was received, documentation was inconsistent/unclear regarding a diagnosis of sepsis. Even 
though sepsis is documented, supporting medical record documentation was not found within the record. Only 
the discharge summary was provided for clinical review. There was no evidence of a rise of 2 or more points in 
the SOFA score that cannot be easily explained by causes other than sepsis after fluid resuscitation. The review 
indicates that  the principal diagnosis code A41.02 - sepsis due to Methicillin susceptible staphylococcus 
aureus was not supported in the medical records. DRG 592 (SKIN ULCERS WITH MCC) is more 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 to the enrollee on September 16, 2021 to September 25, 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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee is receiving acute hospital care, and acute care services have not been 
denied. The documentation does not support that the enrollee in this case requires services at the LTACH that 
are not available at the acute care hospital where she is currently receiving care. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
at this time. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 a breast mammography provided on June 15, 2021. 
 
You asked the Plan to pay for the breast mammography. The Plan denied your request. The Plan says that the 
Plan has paid the maximum amount covered by your Plan for this service. 
 
The Plan contract covers breast screening mammograms every 12 months.  We looked at the file and the Plans rules. The file shows that the Plan paid for a breast mammography 
provided on October 28, 2020. Therefore, we decided that the Plan does not have to pay for a breast 
mammography provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99221, 99231) provided July 7, 2021 to July 8, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim was not billed with a valid place of service. 
 
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 99221, & 99231 is not supported in the medical record. Specifically, the claim was 
submitted with an inpatient place of service (21), however the record shows the enrollee was an outpatient. 
Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. 
Therefore, we decided that the Plan does not have to pay for hospital care (99221, 99231) provided July 7, 
2021 to July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Omegas and Turmeric purchased on January 10, 2022. 
 
You asked the Plan to pay for Omegas and Turmeric. You say that Omegas and Docosahexaenoic Acid (DHA) 
qualify for reimbursement, and you would like the Omegas and Turmeric covered. You say the turmeric has 
been beneficial for you. The Plan denied your request. The Plan says this item is not on your list of covered 
supplements under your supplemental benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the 
Plan offers a supplemental benefit in excess of Medicare coverage. For that reason, the Plans rules apply. 
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the requested supplement is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
Omegas and Turmeric purchased on January 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rhythm electrocardiogram (ECG) provided to the enrollee 
on August 28, 2021. 
 
You asked the Plan to pay for the ECG. You say that this should be paid for. The Plan denied your request. The 
Plan says this was not reported correctly. 
 
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 93042 is "Rhythm ECG, 1-3 leads; interpretation and 
report only." 
 
We asked our coder 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 ECG. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found the documentation does not include 
medical records to confirm the procedure performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ECG have not been met. Therefore, we decided that the Plan does not have 
to pay for a rhythm electrocardiogram (ECG) provided to the enrollee on August 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positional nystagmus test (92532) provided on January 4, 
2022. 
 
You asked the Plan to pay for the positional nystagmus test. You say that this service should be paid. The Plan 
denied your request. The Plan says payment for this service is always bundled into the payment for another 
service. 
 
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 92532 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 92532 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the positional nystagmus test have not been met. Therefore, we decided that the Plan does not have to pay 
for the positional nystagmus test (92532) provided on January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on October 21, 
2021, and October 22, 2021. 
 
You asked the Plan to pay for critical care. You say that these services are supported as billed. The Plan denied 
your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
 
 
 
 
 We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing 
these services is not noted in the record. Based on this information, we decided that Medicare rules for 
coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for 
critical care, first hour (99291) provided on October 21, 2021, and October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implants 
(D6010) provided January 10, 2022. 
 
You asked the Plan to pay for the endosteal implants. You say that you would like this service to at least be 
discounted. The Plan denied your request. The Plan says implants are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical placement of implant body: endosteal implants (D6010) provided January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx test (0037U) provided November 7, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you request the Plan to reverse its original 
decision and cover the claim for FoundationOne CDx. The Plan denied your request. The Plan says does not 
meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
In this case, we find that CPT code 0037U is not supported in the medical record. Specifically, the Plan verified that the genetic testing was not ordered by the ordering provider indicated. The provider's office verified that 
the ordering provider indicted had retired last 12/31 and that there were no records found for this enrollee from 
the ordering provider. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx 
test (0037U) provided November 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mammaprint assay provided on June 25, 2021. 
 
You asked the Plan to pay for the Mammaprint assay. You say that this is medically necessary testing that is 
covered by Medicare. The Plan denied your request. The Plan says this testing is experimental. 
 
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 pay for the Mammaprint assay. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of breast cancer. The case file contains a Test Request Form, 
MammaPrint test results, and a Surgical Pathology Report. No additional clinical medical records are available 
for review. The limited documentation in the case file does not support that the Mammaprint genetic testing 
was medically reasonable and necessary for the enrollee 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 the Mammaprint assay have not been met. Therefore, we decided that the Plan 
does not have to pay for the Mammaprint assay provided on June 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 
17, 2021 to July 7, 2021. 
 
You asked the Plan to pay for home health services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the proper documentation was not submitted to support the billed 
service. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, an 
appropriate Notice of Admission claim was not submitted for these dates of service. Therefore, we decided that 
the Plan does not have to pay for the home health services provided to the enrollee from June 17, 2021 to July 
7, 2021.