Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. There are no acute nursing needs identified or documented. At the current 
functional level, he will not make a significant functional recovery in IRF in a predicted period of time without 
a prosthesis and the enrollee does not need therapy 3 hours a day, 5 days a week. While the enrollee would 
benefit from physical and occupational therapy, the enrollee's rehab needs can be safely provided in an 
alternate and low intensity setting. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from January 1, 2022, to January 5, 
2022. 
 
You asked the Plan to pay for the home health services. You say that the services were paid according to the 
Medicare Allowable. The Plan denied your request. The Plan says that the claim processed correctly. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not supported the reason for their denial in this case. 
Therefore, we decided that the Plan has to pay for the home health services provided from January 1, 2022, to 
January 5, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit received on March 14, 2022, and the 
arthrocentesis services provided on April 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the arthrocentesis services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
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 the office visit received on March 14, 2022, and 
the arthrocentesis services provided on April 14, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from January 31, 
2021, to February 5, 2021, billed with diagnosis related group (DRG) code 070. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 070. You say that you maintain 
the secondary diagnosis code J69.0 (Pneumonitis due to inhalation of food and vomit) should remain as 
originally and compliantly reported. The Plan denied your request. The Plan says DRG 070 is not supported as 
the diagnosis of Pneumonitis due to inhalation of food and vomit. 
 
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 secondary diagnosis code, J69.0, defined as 
Pneumonitis due to inhalation of food and vomit. 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 billed with DRG 070. Our reviewer says that the submitted DRG is not 
supported. Our physician reviewer found the medical records supported the billing of Pneumonitis due to 
inhalation of food and vomit. Our reviewer also found that DRG 070: nonspecific cerebrovascular disorders 
with major complication or comorbidity (MCC) is not appropriate.  
 
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 the inpatient hospital services provided from January 31, 2021, to February 5, 2021, billed with diagnosis 
related group (DRG) code 070.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued SNF care. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs or documented skilled therapy needs. Daily skilled services are not shown to 
be required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs can, as a practical matter, be provided at a lower 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is not a reasonable expectation that this patient will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device segmental home model 
with calibrated gradient pressure (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device segmental home model with calibrated 
gradient pressure. You say that this is medically reasonable and necessary for the enrollee's condition. The Plan 
denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen. 
 
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 for the pneumatic compression device. Our reviewer says that the enrollee is an 80-year-old female with a diagnosis of bilateral lower extremity lymphedema. Our 
physician reviewer found that based on the medical records provided there is no documentation that the 
pneumatic compression device (E0652) at issue in this case meets Medicare criteria for coverage. In this case, 
the records do not document that the enrollee's lymphedema has extended onto the chest, abdomen or trunk as 
required by the LCD. 
 
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 PCD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device segmental home model with calibrated gradient pressure 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve care and services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the care and services. You say that you are recommending the enrollee to 
see this provider for her shoulder pain. You say the enrollee does not have a good rapport with the only in-
network provider who performs shoulder nerve ablations. The Plan denied your request. The Plan says the 
provider 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the care and services We found no exception that would require the Plan to pre-
approve the care and services. Therefore, we decided that the Plan does not have to pre-approve care and 
services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided from January 
29, 2022, to February 27, 2022. 
 You asked the Plan to pay for the SNF stay. You say that the SNF stay was medically necessary. The Plan 
denied your request. The Plan says the enrollee was clinically stable, not in acute distress, and the enrollee's 
care could have been provided at a custodial 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 pay for the SNF stay. Our reviewer says that based 
on the documentation provided, the enrollee no longer qualified for SNF coverage. Our physician reviewer 
found that the enrollee did not have documented skilled nursing or skilled therapy needs. Our physician 
reviewer found that daily skilled services were not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
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 stay have not been met. Therefore, we decided that the Plan does not 
have to pay for a skilled nursing facility (SNF) stay provided from January 29, 2022, to February 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contract that 
indicates that payment for laboratory testing is included in payment for dialysis. The Plan denied your request. 
The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial and subsequent hospital care services (99221, 99223, 
99232) provided from December 13, 2021, to December 16, 2021. 
 
You asked the Plan to pay for hospital care. You say that these services were provided by multiple providers on 
the dates in question. The Plan denied your request. The Plan says these services were not reported in 
accordance with Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that both Initial Hospital Care and Subsequent Hospital Care codes are per diem services 
and may be reported only once per day by the same physician or physicians of the same specialty from the 
same group practice. 
 We find that the services at issue are not supported in the record provided. Specifically, initial hospital care 
(99223) and subsequent hospital care services (99233, 99232) were billed by this same provider with the same 
name and same national provider identifier (NPI) for the enrollee on the dates in question. Although different 
codes were used in some cases, the rules say that these code groups are per diem services which may only be 
reported once per day by the same physician. The record also shows that this previous claim for initial and 
subsequent hospital care services rendered by the same provider was paid on March 15, 2022. Based on this 
information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we 
decided that the Plan does not have to pay for initial and subsequent hospital care services (99221, 99223, 
99232) provided from December 13, 2021, to December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 16, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be covered. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pristiq. 
 
You asked the Plan to pre-approve Pristiq. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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. Therefore, we decided that the Plan does not have to pre-approve Pristiq.  
 
 
 
 
 Benefits for Pristiq 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclobenzaprine for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee has been using this with a positive 
outcome. The Plan denied your request. The Plan says that this is not covered under Part B. 
 
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 Cyclobenzaprine for the 
enrollee.  
 
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation and testing to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the consultation and testing. You say that you are covered for a computed 
tomography (CAT) scan, so you should get this visit with this doctor. You say you believe this scan would be 
preventive because it might be cancer. The Plan denied your request. The Plan says the provider 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the consultation and testing. We found no exception that would require the Plan to 
pre-approve the consultation and testing. Therefore, we decided that the Plan does not have to pre-approve the 
consultation and testing to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroxyzine hydrochloride. 
 
You asked the Plan to pre-approve Hydroxyzine hydrochloride. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Hydroxyzine hydrochloride.  
 
Benefits for Hydroxyzine hydrochloride 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory testing to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve laboratory testing. You say that the laboratory testing is needed because the 
biomarker results will be used to help develop the most appropriate treatment plan for the enrollee. The Plan 
denied your request. The Plan says the provider 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the laboratory testing. We found no exception that would require the Plan to pre-
approve the laboratory testing. Therefore, we decided that the Plan does not have to pre-approve laboratory 
testing to be provided by an out-of-network (OON) provider.