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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances with a wheeled walker with close supervision and is supervision for transfers. Provided 
records do not document a significant decline in your functional status to necessitate daily inpatient skilled 
therapy services. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. 
Records do not document that services in the home with home health care or in a long-term care facility on a 
part time basis are not 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 skilled nursing facility (SNF) care.
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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee received medications and had 
stable vital signs. The enrollee was at a dependent to moderate assist of 2 level for functional mobility. 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rTMS. 
 
You asked the Plan to pre-approve rTMS. The Plan denied your request. The Plan says rTMS is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that rTMS of the brain is considered medically necessary 
for use in an adult who has a confirmed diagnosis of severe major depressive disorder (MDD) single or 
recurrent episode 
 
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 rTMS. Our reviewer says that rTMS is 
not medically necessary. Our physician reviewer found that based on review the records provided and utilizing 
the Medicare local coverage determination LCD specifically for repetitive transcranial magnetic stimulation 
(L37088) requires the confirmed diagnosis to be Severe Major Depressive Disorder Single or Recurrent as well 
as resistance the treatment with pharmacologic agents as evidenced by lack of clinical significant response to 
for trials of pharmacologic agents in the current depressive episode from at least two different agent classes 
along with concurrent documented psychotherapy. This enrollee does possess the diagnosis as noted above. 
She had been tried on pharmacologic agents from different categories for which she has had very little 
improvement although it is unclear what episode of depression this patient had taken these medications as it is 
not outlined as a current episode. There is no mention of the enrollee desiring electroconvulsive treatment even 
though it is in the record. Utilizing the information from this enrollee that indicates she does have an indication for the requested rTMS. Based on the records provided. This enrollee does not meet the criteria or treatment 
with rTMS as she is not diagnosed with having Severe Major Depressive Disorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rTMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve rTMS.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal endoscopy services provided on May 27, 2021. 
 You asked the Plan to pay for the services provided. You say that the enrollee had bilateral sinus surgery. The 
Plan denied your request. The Plan says the service was not billed in accordance with guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 31237 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the nasal 
endoscopy services provided on May 27, 2021.
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 daily 
skilled services are not necessary. Our physician reviewer found you received medications and had stable vital 
signs. You were at a dependent to maximal assist level for functional mobility including gait to 15 feet. 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 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: 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 the SNF services. You say that you would like reconsideration because the 
SNF admission is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare 
criteria 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found 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.  Your  physical function is at or near baseline and you can 
receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehab 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 the 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: 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 daily 
skilled services are not necessary. Our physician reviewer found you received topical medications and insulin. 
You had stable vital signs and your lungs were clear. You were at a maximal assist level with bed mobility and 
non-ambulatory. 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 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home mechanical ventilator. 
 
You asked the Plan to pre-approve the home mechanical ventilator. You say that you would like 
reconsideration because the ventilator is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 mechanical ventilator. Our 
reviewer says that there is a diagnosis of COPD but no documentation with pulmonary function tests.  There is 
no neuromuscular disease or thoracic restrictive disease. Our physician reviewer found the enrollee has been 
non-compliant with CPAP and home ventilator in the past.  This enrollee may benefit from BiPAP during sleep, which can provide the AVAPS mode of support. There is no documentation of BiPAP failure at home 
while stable.  Medicare does not cover a home ventilator when used as BiPAP. 
 
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 mechanical ventilator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the home mechanical ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 31, 2021, to 
April 12, 2021, at the Diagnosis Related Group (DRG) billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG billed. You say that N17.0 (acute 
kidney failure with tubular necrosis) is a valid diagnosis for this encounter because the patient's lab values 
support it. The Plan denied your request. The Plan says the secondary diagnosis of N17.0 (acute kidney failure 
with tubular necrosis) is not supported in the medical record, resulting in a lower DRG being paid. 
 
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 the secondary diagnosis code of N17.0 (acute 
kidney failure with tubular necrosis). 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 
inpatient hospital services at the DRG billed. Our reviewer says that the medical records do not support a 
secondary diagnosis of N17.0 (acute kidney failure with tubular necrosis). Our physician reviewer found the 
patient is an 81 year old female who was admitted and treated in the hospital for bowel obstruction. Blood Urea 
Nitrogen (BUN) was noted to be 18 mg/dl (normal) and Creatinen (Cr) 1.01 to 1.51 mg/dL (>0.3 within 2 
days). The patient's BUN/Cr ratio was 17. The patient was treated with fluids and Cr returned to baseline 0.58 
in less than 3 days of treatment. Also, U/A did not show signs of Acute Tubular Necrosis (ATN) (non-hyaline 
casts). There were no other confirmation tests performed to specifically confirm ATN, although acute kidney 
failure is a reasonable diagnosis (without ATN).   
 
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 on March 31, 2021, to April 12, 2021, at the Diagnosis Related Group 
(DRG) billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documents. The Plan denied your request. The Plan says the claim has denied correctly based 
on Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 4, 2021. 
 
You asked the Plan to pay for the services provided. You say that  The Plan denied your request. The Plan says 
the services are not eligible for reimbursement. 
 
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 A4930 is gloves, sterile, per pair. We find that the 
payment for CPT code A4930 is packaged into payment for other services. This service is not eligible for 
separate payment.  
 
 The CPT Code Manual definition of code J8499 is prescription drug, oral, non-chemotherapeutic, nos. We find 
that CPT code J8499 is not paid by Medicare when submitted on outpatient claims.  
 
The file shows that the enrollee received services during an emergency department visit. The codes at issue are 
not payable as billed. Based on this information, we decided that Medicare rules for coverage of the services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for the services provided 
on December 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy of a nail unit (11755) provided on December 3, 
2021. 
 You asked the Plan to pay for the biopsy of a nail unit. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 11755 
and 11730. 
 
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 11755 is a column II code to column I code 11730; however, 11755 
was billed with a modifier.  
 
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 biopsy of a nail unit. Our reviewer says that CPT code 
11755 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure 
report describes two procedures performed on the same toe. Per CMS guidelines, the description of CPT codes 
11730, 11732 and 11750 indicates partial or complete avulsion or excision of a nail plate. When CPT code 
11730, 11732 or 11750 is reported, it represents all services performed on that nail for that date of service 
(DOS). When lateral and medial sides of a nail are involved, do not report a separate code for each border.   
Therefore, this procedure would be inclusive to CPT 11730. 
 
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 biopsy of a nail unit have not been met. Therefore, we decided that the Plan 
does not have to pay for the biopsy of a nail unit (11755) provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic testing services provided on February 17, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the service was medically necessary and 
approved in good faith. The Plan denied your request. The Plan says utilization of network providers and 
authorization for certain services are required. 
 
 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 and the referring provider in this case are not a network providers with the Plan. The 
Plan did not pre-approve the services 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 the diagnostic testing services 
provided on February 17, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee is having surgery and 
needs the hospital bed during the post-operative recovery period. The Plan denied your request. The Plan says a 
semi-electric bed is covered when the enrollee needs special positioning; or special attachments that cannot be 
used on a regular bed. The Plan also says the enrollee does not need special positioning or attachments. The 
item does not meet criteria. 
 
 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on July 7, 2021.