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 SNF services are necessary because the enrollee is 
unsteady and needs more physical therapy. The Plan denied your request. The Plan says the requested SNF 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. 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. 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure code 99236) rendered on July 11, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support the level of care. 
 
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 99236 is "Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
does not support the CPT code 99236. The documentation available for review does not support that the 
presenting problems were of high severity or that the medical decision was of high complexity. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital care (procedure code 99236) rendered on July 11, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services provided from September 12, 2021, to 
September 14, 2021. 
 
You asked the Plan to pay for the services provided. You say that all codes are assigned correctly. The Plan 
denied your request. The Plan says that payment was made according to the ambulatory payment classification 
requirements. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The explanation of benefits provided show a denial message that the reversal is due to a resubmission/change 
to the claim by the provider. The Plan has not provided the claim at issue, or specifics about why a reversal was 
warranted. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the outpatient 
hospital services provided from September 12, 2021, to September 14, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 25, 2022, to July 
6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the rendering hospital is out-of-network. 
 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 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 inpatient hospital services provided on June 25, 
2022, to July 6, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says that Medicare requires that the member 
attempt at least four weeks of conservative care and the documentation does not indicate that the member has 
completed physical therapy. 
 
The Plan follows Medicare rules. 
 
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 epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is medically necessary in this case. Our physician 
reviewer found that this 66-year-old enrollee has chronic low back pain. The enrollee had prior spine surgery in 
1996. The enrollee has tried and failed conservative therapy such as chiropractic care, physical therapy, over 
the counter medications, hydrocodone, exercises and stretching. The enrollee is presently in physical therapy at 
since mid-January 2023. The magnetic resonance imaging (MRI) from December 12, 2022, shows posterior 
disc bulge and bilateral facet hypertrophy at L5-Sl causing moderate to severe bilateral neural foraminal stenosis. The enrollee has clearly documented pathology and has failed conservative therapy. The requested 
epidural steroid injection is medically reasonable and 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 an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist arthroscopy (29846) provided on August 24, 2022. 
 
You asked the Plan to pay for the wrist arthroscopy (29846). The Plan denied your request. The Plan says 
procedure code 29846 is considered inclusive to procedure code 25609. 
 
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 29846 is arthroscopy, wrist, surgical; excision and/or 
repair of triangular fibrocartilage and/or joint debridement. 
  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 wrist arthroscopy (29846). Our reviewer says that 
procedure code 29846 is not supported. Our reviewer found that the arthroscopy was used for guidance, not a 
separate diagnostic procedure. According to National Correct Coding Initiative (NCCI) rules, an arthroscopy is 
included in the open procedure. 
 
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 wrist arthroscopy (29846) have not been met. Therefore, we decided that the 
Plan does not have to pay for the wrist arthroscopy (29846) provided on August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on June 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit".  
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 services. Our reviewer says that the use of code 99223 is 
not supported by the records provided. Our reviewer found that the provided medical records do not document 
medical decision making of high complexity with an extensive number of diagnoses or management options, 
an extensive amount and complexity of data reviewed and high risk of complication. Despite reports of 
encephalopathy, weakness and altered mental status, the objective data in the physical examination and vital 
signs did not support a high risk of complication with normal vital signs, no hypoxemia on room air, a normal 
documented physical examination except for the presence of the urinary catheter and normal laboratory data 
and imaging except for anemia, hematuria and a possible soft tissue hematoma. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99223) provided on June 13, 2022.
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 you need more care than what you can 
receive in a skilled nursing facility. You say you are having trouble with your feeding tube, and you need to see 
a specialist every day. The Plan denied your request. The Plan says you do not meet the guidelines for care in 
an LTACH. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The Plan has approved ongoing care in the current acute care 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing helps achieve a differential diagnosis. 
The Plan denied your request. The Plan says the service is excluded from coverage. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Screening services such as pre-symptomatic tests and services used 
to detect an undiagnosed disease or disease predisposition are not a Medicare benefit and are not covered. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder. You say that the provider is suspicious that 
cardiac arrhythmia is the cause of the enrollee's condition. The Plan denied your request. The Plan says that the 
service is not medically necessary. 
 
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 implantable loop recorder. Our 
physician reviewer found with recent transient ischaemic attacks (TIA), and history of rare occasions of 
palpitation, but never documented atrial fibrillation. Therefore, the enrollee will benefit from long-term 
implantable heart rhythm monitoring (loop recorder). 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 implantable loop 
recorder have been met. Therefore, we decided that the Plan has to pre-approve the implantable loop recorder 
(ILR) (33285).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on July 16, 2022, billed with 
code 70706-26. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is not consistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the radiology services provided. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records did not reveal the patient with a family or 
personal history of aortic aneurysm, with a significant smoking history or other risk factors to qualify them for 
AAA screening based on current guidelines. 
 
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 radiology services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for radiological services provided on July 16, 2022, billed with code 70706-26.
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 you believe this enrollee's health and 
recovery need the additional care provided by an LTACH, and you would like the transfer to be approved. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
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 documentation does not support that the enrollee has a need for complex medical 
treatment in an LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. Our reviewer found that the requested treatments are not medically 
necessary at the LTACH level of care. Our physician reviewer also found that the enrollee has improved 
medically and can receive further care at the current acute care hospital or a lower level of care when deemed 
appropriate. 
 
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 pre-approve a continuation of care with an out-of-network (OON) 
urologist. 
 
You asked the Plan to pre-approve a continuation of care with an OON urologist. You say that you are an 
established patient of the requested OON provider and are in the middle of exploratory services concerning 
possible prostate surgery. You say that you were misadvised that this OON provider was in-network when you 
were choosing your coverage. The Plan denied your request. The Plan says there are in-network urologists who 
can treat the enrollee. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an OON 
urologist. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the record indicates that you have an elevated prostate specific antigen, erectile dysfunction, 
and benign prostatic hypertrophy.  The record provided does not indicate that you are receiving active 
treatment of any of your conditions at this time, such that transferring your care and medical management to 
another provider would be medically inappropriate and/or contraindicated at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continuation of care with an OON urologist have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
urologist.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).