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

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you are not able to safely transfer and need more assistance while regaining strength. You state you have COVID-19 and need time to recover and regain straight in skilled nursing prior to having COVID-19. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the services you require, such as additional therapy services, can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
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 daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 the enrollee was admitted for left thoracoscopy left atrial appendage closure with 
atrial clip and removal of left subclavian pacemaker generator. The record indicates that the enrollee has had a 
prolonged hospital course and continues to require acute care services. The record indicates that the enrollee 
requires on going acute care services. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be recommended. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on May 24, 
2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 70450 may be eligible for payment when billed with CPT code 70496. The claim does 
not show that a modifier suitable for payment was billed. Based on this information, we decided that Medicare 
rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay 
for the computed tomography (CT) scan provided on May 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need this level of care. The Plan denied 
your request. The Plan says that your care could be provided at a lower level of 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 necessary. Our physician reviewer found that your 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 20, 2021. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim provided lists a place of service as an independent laboratory. We looked at the file and the rules. If 
an independent lab bills for services, the place where the sample was taken is reported as the place of service. 
The records do not show that the specimen was obtained at an independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing services provided on July 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76705) provided on October 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
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. In this case, we have confirmed that code 76705
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the services (76705) provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided the Plan does not have to pay for physician services provided on September 17, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 physician services provided to the enrollee on 
September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95822) provided on February 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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. In this case, we have confirmed that code 95822 
is a column II code to column I code 51785. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (95822) provided on February 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on June 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by the network facility from November 18, 2021, to November 24, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the copayment since this hospital stay was due to complications from your surgery. The Plan denied your request. The Plan says you have been asked to pay 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 $315 copayment per stay for Medicare-covered inpatient hospital stays.
You have been asked to pay a $315 copayment for the inpatient hospital stay. The inpatient hospital stay 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 stay provided by the network facility from November 18, 2021, to November 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octreotide injection (J2353). 
 
You asked the Plan to pre-approve Octreotide. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the requested drug is not FDA approved for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Octreotide. Our reviewer says that the 
requested Octreotide injection is not medically necessary. Our physician reviewer found the requested drug is 
not approved by the Food and Drug Administration (FDA) for the enrollee's condition. The reviewer found that 
the Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in 
the enrollee's clinical situation. Therefore, the reviewer found that the requested drug is not medically 
reasonable or 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 Octreotide have not been met. Specifically, the file does not indicate that the 
requested drug is not approved by the Food and Drug Administration (FDA) for the enrollee's condition. 
Therefore, we decided that the Plan does not have to pre-approve Octreotide injection (J2353).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from January 23, 
2021, to February 14, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
are not separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The file shows that the enrollee received routine services including, but not 
limited to, dialysis, oxygen, blood draws, and intravenous care. The services at issue are considered packaged. 
The payment is packaged into payment for other services. Therefore, there is no separate payment.  
 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 inpatient hospital services provided from January 23, 2021, to 
February 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humulin R. 
 
You asked the Plan to pre-approve Humulin R. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humulin R.  
 
Benefits for Humulin R 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on November 9, 2021.
You asked the Plan to pay for the dental item. You say that you were advised by your dentist that this service
would be covered. You say that you were not informed of the large cost. You also say that if you had known it
would not be covered, you would have refused. The Plan denied your request. The Plan says occlusal guard is
not listed as a covered dental item.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the occlusal guard is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard
(D9944) provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator purchased on May 18, 2021. 
 
You asked the Plan to pay for this equipment. You say that this equipment should have been covered by the 
Plan. The Plan denied your request. The Plan says you did not have prior authorization to purchase out of 
network oxygen equipment. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees must use in network providers and durable medical equipment requires prior 
authorization. You did not follow your Plan contract agreement when you purchased this equipment.  
Therefore, we decided that the Plan does not have to pay for an Inogen oxygen concentrator purchased on May 
18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the member has stabilized medically and is 
ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy 
services on a daily basis. The member is 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 SNF. The 
member does not have any parental medication; complex wound care or nutrition given via a feeding tube. The 
member is medically stable without any acute exacerbations of chronic medical problems. The member's 
physical function is at or near their baseline and they 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs that level of care. The Plan 
denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states 
the clinical information indicates that the enrollee's needs may be safely met at an alternate level of care. The 
Plan states the enrollee's needs can be met at home with supervision and home health services and the enrollee's 
doctor will need to order home health services, which will then be reviewed for coverage. 
 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 daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary 
and reasonable treatment. Records do not document the need for intravenous medications, new tube feeding, or 
ostomy care or daily complex wound care. This enrollee does require skilled therapy services, i.e., the 
specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide 
medically necessary and reasonable treatment. Daily skilled services are not required. The enrollee is walking 
household distances with stand-by assistance and is contact guard to stand-by assist for transfers. This enrollee 
does not require the services on an inpatient basis, only in a SNF setting. Services in the home with home 
health care or in a long-term care facility on a part time basis appear 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83550, 83540, 82310, 83970, 87340, 
and 84100) provided August 4, 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 these 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 82728, 83550, 83540, 82310, 83970, 87340, and 84100 is not supported in the medical 
record. Specifically, laboratory tests are included in dialysis services when performed for the treatment of End-
stage renal disease. 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 lab services (82728, 83550, 
83540, 82310, 83970, 87340, and 84100) provided August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure (97110) provided August 27, 2020. 
 
You asked the Plan to pay for the therapeutic services. You say that please review all attached documentation 
supporting this request and process the claim for payment. The Plan denied your request. The Plan says code 
not appropriate for 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 97110 GP CQ KX (4 units) is therapeutic procedure, 1 or 
more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and 
flexibility. 
 We find that CPT code 97110 GP CQ KX (4 units) is not supported in the medical record. Specifically, the 
submitted records indicates that PTA visit was performed at a home setting. There is a more appropriate 
healthcare common procedure coding system (HCPCS) code (G0157) that should be used to bill for the service 
provided. Also, the medical record does not include documentation of the Plan of Care, and the GP modifier is 
not supported. Based on this information, we decided that Medicare rules for coverage of the therapeutic 
services have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedure 
(97110) provided August 27, 2020.