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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and his lungs were clear. He was at a modified independent to supervision level for functional 
mobility including gait to 90 feet. The enrollee does not require skilled nursing or therapy services on a daily 
basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vest Airway Clearance System (E0483). 
 
You asked the Plan to pre-approve a Vest Airway Clearance System. You say that the requested vest is 
medically necessary. The Plan denied your request. The Plan says the requested vest does not meet Medicare 
criteria. 
 
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 a Vest Airway Clearance System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of chronic obstructive pulmonary disease and 
acute on chronic bronchitis and prior COVID pneumonia. Provided records do not document bronchiectasis, 
cystic fibrosis or a neuromuscular disease in this case. Criteria for coverage is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vest Airway Clearance System have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Vest Airway Clearance System (E0483).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of home health physical therapy services 
(CPT code G0151). 
 
You asked the Plan to pre-approve the home health physical therapy services. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee will not progress further with additional 
physical therapy due to cognitive issues. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health physical therapy 
services. Our physician reviewer found the records do not show that skilled therapy services are required to 
effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent 
deterioration. The documentation indicates the enrollee is confused with significant cognitive deficits which 
would impair therapy carryover. The does not reveal that the enrollee's functional level requires ongoing skilled 
therapy services. The requested home health physical therapy services are not reasonable and necessary to the 
treatment of the enrollees illness or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home health physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuation of home health physical therapy services (CPT 
code G0151).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 4MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that this medication is requested for prevention of 
nausea postoperative surgery. The Plan denied your request. The Plan says Ondansetron is a self-administered 
drug and does not fall under Part B coverage. 
 
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. Furthermore, Medicare also covers self-administered anti-emetics, which are necessary for 
the administration and absorption of the anti-neoplastic chemotherapeutic agents when a high likelihood of 
vomiting exists. However, this medication is to be used after bariatric surgery to help with nausea. Therefore, 
we decided that the Plan does not have to pre-approve Ondansetron 4MG tablet.  
 
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle-foot orthosis (AFO), posterior solid ankle, 
plastic, custom fabricated (L1960). 
 
You asked the Plan to pre-approve an ankle-foot orthosis. You say that the requested orthosis is medically 
necessary. The Plan denied your request. The Plan says the ankle-foot orthosis does not meet criteria; the 
request is not medically necessary. 
 
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 ankle-foot orthosis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is unable to perform daily activities of daily living and is at risk of falling 
due to instability of her knee without brace. There is no justification for a custom AFO brace. An off the shelf 
AFO is most appropriate in this case. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ankle-foot orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an ankle-foot orthosis (AFO), posterior solid ankle, plastic, custom fabricated 
(L1960).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item was exhausted on date of service October 20, 2020. Specifically, the 
Plan contract states that a complete lower denture is covered once every five years. You previously received 
this item on October 20, 2020, which was paid for by the Plan. Therefore, you have exhausted the allowable 
benefit. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that daily skilled services are not required. 
 
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 
SNF services are not medically reasonable and necessary. There is no documentation that the patient requires 
skilled nursing or therapy services. There is no documentation that daily skilled services are required. Provided 
records do not document a significant decline in the patients functional status compared to her recent baseline 
to necessitate daily inpatient skilled nursing or therapy services. There is no documentation that the patient 
requires the services on an inpatient basis, only in a skilled nursing facility setting. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided 
from February 25, 2022, to February 26, 2022. 
 
 
You asked the Plan to waive the copayment for the inpatient hospital admission. You say that should not be 
responsible for the cost share for this claim as you were told you would be in and out. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
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 a $100 
copayment per admission.  
 
You have been asked to pay a $100 copayment for an inpatient hospital admission. The inpatient hospital admission falls within the Inpatient Hospital Care 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 the inpatient hospital admission provided from February 25, 2022, to February 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery which was an 
injection of a substance into lower spine canal using imaging guidance provided on May 2, 2022. 
 
You asked the Plan to waive the copayment for the injection. You say that this was not an office visit, it was a 
back injection only. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 a $35 
copayment for each specialist's office visit.  
 
You have been asked to pay a $35 copayment for an outpatient surgery at a specialist's office. The injection 
falls within the Outpatient Surgery, Including Services Provided at Hospital Facilities and Ambulatory Surgical 
Centers 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 the outpatient surgery 
which was an injection of a substance into lower spine canal using imaging guidance provided on May 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiologic examination (X-ray) of the 
chest provided on December 30, 2021. 
 
You asked the Plan to waive the copayment for the X-ray. You say that you had covid and this claim should be 
adjusted to remove the copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 a $15 
copayment for each standard X-ray.  
 
You have been asked to pay a $15 copayment for a standard X-ray. The X-ray falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and 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 copayment for the radiologic examination (X-ray) of the chest provided on December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99153) provided December 30, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, this service has a 
professional component / technical component indicator of 3 and is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for anesthesia services (99153) provided December 
30, 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 appears to be stable and improving and should only require short-term 
additional acute care services that can safely be administered at the current facility until more appropriate for a 
lower level of care. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to LTACH is not medically necessary 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99244) provided December 21, 2021. 
 
You asked the Plan to pay for the physician services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 99244 is not supported in the medical record. Specifically, the record show this was a 
telehealth service, however the provider has not billed it as a telehealth visit. Based on this information, we 
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided 
that the Plan does not have to pay for physician services (99244) provided December 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
the admission is not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on August 6, 2022 and transferred to inpatient psychiatric care on August 11, 2022. The note dated 
August 20, 2022 does not document any major issues. There are no physical or occupational therapy records in 
the submitted documentation. There is no documentation that the enrollee has skilled nursing or skilled therapy 
needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the 
enrollee does not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
the admission is not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital and underwent surgical debridement. The note dated August 18, 2022 states he was completing 
antibiotics for sepsis and had C. difficile infection. End stage renal disease was managed by nephrology. He 
has no documented skilled nursing needs. It is not clear that he has any daily wound care needs or that he is still 
receiving intravenous (IV) antibiotics. He has no skilled therapy needs. As a practical matter, the enrollee does 
not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88312, 88305) provided on April 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services (88312, 88305) provided on April 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (88305, 88312) provided August 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 88305 and 88312 are not supported in the medical record. Specifically, the services 
have a professional / technical component indicator of 1. The enrollee was an outpatient at the time services 
were provided. The facility billed the same service on the same date. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services (88305, 88312) provided August 17, 2021.