Persius/hicric huggingface dataset:
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 you need more aggressive therapy and a better level 
of care to return home. The Plan denied your request. The Plan says that the services you need can be provided 
safely in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia, urinary tract 
infection, and a wrist fracture. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a hospital bed provided January 13, 2022, to 
February 13, 2022. 
 
You asked the Plan to waive the deductible for a hospital bed. You say that you should not be responsible for 
this because the supplier is out-of-network and the billing is in-network. The Plan denied your request. The 
Plan says you are responsible to pay $169.82. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $490 deductible which applies to Durable Medical Equipment (DME) 
and Related Supplies.  
 
 
 
 
 
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
Medical Equipment (DME) and Related Supplies. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $490 deductible which applies to durable medical equipment. This cost sharing is 
a contractual obligation that had not been met at the time the hospital bed was received on January 13, 2022, to 
February 13, 2022. Therefore, we decided that the Plan does not have to waive the deductible for a hospital bed 
provided January 13, 2022, to February 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you are requesting to re-start therapy as 
there was a delay in rehabilitation due to your skin issues. The Plan denied your request. The Plan says you no 
longer require daily skilled therapy to improve or maintain your condition. 
 
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 SNF admission. Our reviewer says 
that you have multiple comorbidities and was receiving skilled services in a SNF after hospitalization for 
cellulitis. You were discharged from daily skilled services and are now requesting to restart daily skilled 
services in a SNF. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
Our reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to a pre-approve a SNF admission.
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 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. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for COVID-19 and a fall. He is now medically stable with no complex nursing or rehabilitation needs. 
He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee 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 the gene panel testing provided on December 13, 2021. 
 
You asked the Plan to pay for the testing services. You say that the results of the testing assist in the 
management of the enrollee's cancer. The Plan denied your request. The Plan says the testing is not a Medicare 
benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The testing services in this case includes the FANCC gene. Panels 
that include this gene are statutorily excluded. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel testing 
provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography of the larynx (95865) and 
neurophysiology monitoring (95941) provided on March 9, 2022. 
 
You asked the Plan to pay for needle electromyography of the larynx and neurophysiology monitoring. You 
say that the services billed were a medical necessity for the enrollee. The Plan denied your request. The Plan 
says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that the diagnoses codes listed in the rules support 
medical necessity for CPT code 95865. Medicare 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. In this case, the diagnosis code billed for the services at issue is 
E21.3. This code is not listed in the rules as supporting medical necessity for CPT code 95865. Furthermore, 
we find that CPT code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of needle electromyography of the larynx and neurophysiology monitoring have not been met. 
Therefore, we decided that the Plan does not have to pay for needle electromyography of the larynx (95865) 
and neurophysiology monitoring (95941) provided on March 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance stabilization provided on 
February 21, 2022. 
 
You asked the Plan to waive the copayment for ambulance stabilization. You say that you shouldn't be charged 
for this. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $250 
copayment for each non-Medicare covered ambulance stabilization when there is no transport. 
 
You have been asked to pay $250 copayment for ambulance stabilization. Ambulance stabilization falls within 
the Ambulance 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 copayment for ambulance 
stabilization provided on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement in place that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the services are the responsibility 
of the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99221-AI) billed for date of service 
March 6, 2021. 
 
You asked the Plan to pay for initial hospital care billed with code 99221-AI. You say that this enrollee was 
seen by multiple providers on the date in question. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim to the same provider and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 9, 2021. Comparison of the two claims shows these are exact duplicates and 
the provider in both cases is the same nurse practitioner. There is no evidence presented to support that the 
billed items/services were provided twice by the same provider on the same date. Based on this information, we 
decided that the Medicare rules for initial hospital care billed with code 99221-AI have not been met. 
Therefore, we decided that the Plan does not have to pay for initial hospital care (99221-AI) billed for date of 
service March 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on January 
24, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you went for a routine exam. You 
also say there was never any use of lasers, and you do not wear glasses. The Plan denied your request. The Plan 
says this benefit 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. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for 
puckering of macula, left eye, vitreous degeneration, bilateral, and combined forms of age-related cataract, 
bilateral. You are responsible for a $40 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 (92014) provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for urostomy supplies provided on April 5, 
2022. 
 
You asked the Plan to waive the coinsurance for urostomy supplies. You say that you never paid this much in 
the past so you shouldn't have to now. The Plan denied your request. The Plan says the coinsurance applied is 
correct. 
 
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 20% 
coinsurance for Medicare-covered medical supplies.  
 
You have been asked to pay $3.89 which is 20% of the allowed amount for urostomy supplies. The allowed 
amount is $29.65 (20% x $29.65= $3.89). Urostomy supplies falls within the Prosthetic Devices and Related 
Supplies 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 coinsurance for urostomy supplies 
provided on April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has not been billed as required by 
Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the auricular peripheral nerve stimulation device. 
 
You asked the Plan to pre-approve the auricular peripheral nerve stimulation device. You say that this is 
medically necessary for your condition. The Plan denied your request. The Plan says this device is not covered 
per Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation 
of auricular acupuncture points are non-covered as acupuncture for stimulation of auricular points is not a 
covered Medicare benefit. Based on this information, we decided that Medicare rules for coverage of the 
auricular peripheral nerve stimulation device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the auricular peripheral nerve stimulation device.
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 an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the medical criteria for an IRF admission has not been met. 
 
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 while the enrollee may benefit from continued physical therapy and occupational 
therapy, the enrollee's rehab needs can be safely provided in a lower intensity and alternate setting such as 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 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 the targeted genomic sequence analysis provided on 
December 18, 2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include testing for the FANCC gene 
are not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the panel provided included testing for 
the FANCC gene. This means the entire panel is not covered. Based on this information, we decided that 
Medicare rules for coverage of the targeted genomic sequence analysis have not been met. Therefore, we 
decided that the Plan does not have to pay for the targeted genomic sequence analysis provided on December 
18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee requires skilled nursing as 
recommended by the physician at the current facility. The Plan denied your request. The Plan says based on the 
enrollee's current medical condition, care within an assisted-living facility with home physical/occupational 
therapy and/or 24 by 7 care is recommended. 
 
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 SNF admission. Our reviewer says 
that the enrollee does not qualify for SNF coverage. Our physician reviewer found the enrollee does not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. Our reviewer also found that the enrollee does not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SNF admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from July 11, 2021, through July 
26, 2021, at DRG 871. 
 
You asked the Plan to pay for inpatient services at DRG 871. You say that the diagnosis codes were noted in 
the emergency room report, event note, anesthesia evaluation notes, consultation reports and progress notes. 
You say that it is clear from the records the diagnosis codes were removed in error and the claim should be 
reprocessed to pay DRG 871. The Plan denied your request. The Plan says diagnosis codes A41.9, R65.20 and 
J96.01 are not 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 billed with principal diagnosis code A41.9, defined as sepsis, 
unspecified organism, secondary diagnosis code R65.20, defined as severe sepsis without septic shock and 
secondary diagnosis code J96.01, defined as, cute respiratory failure with hypoxia. 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 inpatient services at DRG 871. Our reviewer says that the 
documentation does not support diagnosis codes A41.9, R65.20 and J96.01. Our physician reviewer found the 
documentation does not support a manifestation of systemic infection beyond that evidenced by criteria. 
Although a diagnosis of sepsis was noted during the stay, there was no evidence of significant 
thrombocytopenia, hepatic or renal dysfunction, acute mental status changes or persistent hypotension.  
 
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 services provided from July 11, 2021, through July 26, 2021, at DRG 871.