Persius/hicric huggingface dataset:
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 placement and are medically stable at 
the hospital. You say that the next appropriate level of rehabilitation care would be at a SNF. The Plan denied 
your request. The Plan says the enrollee does not meet the guidelines for coverage. The Plan says that the 
enrollee is not noted to have any daily skilled nursing needs. The Plan says that the enrollee's needs can safely 
be received at a different setting.  
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 there is no documentation that the 
enrollee requires skilled nursing services, intravenous medications, new tub feeding, ostomy care, or daily 
complex wound care. The enrollee does require skilled therapy services. However, the skilled therapy services 
are not required on a daily basis. The enrollee has reportedly been non-ambulatory and in need of significant 
assistance with transfers and activities of daily living for months. The enrollee's present functional status does 
not appear to be significantly different than his recent baseline. The enrollee does not require the services on an 
inpatient basis, only in a SNF setting. Services 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 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 laboratory services provided on April 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 14, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complex chronic care management services (99487, 
99489) provided September 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the complex chronic care management services. You say that the services 
provided were medically necessary. The Plan denied your request. The Plan says you did not obtain prior 
authorization for these OON services. 
 
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 complex chronic care management services 
(99487, 99489) provided September 29, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee on September 
22, 2021. 
 
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 procedures are an invalid combination for vaccine. 
 
  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on 
September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayment for the 
esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) provided on  
October 20, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $225 
copayment for each Medicare-covered ambulatory surgical center visit.  
 
 You have been asked to pay a $225 copayment for the ambulatory surgical center visit provided. 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 issue reimbursement of the copayment for the esophagogastroduodenoscopy, flexible, 
transoral; with biopsy, single or multiple (43239) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7140). 
 
You asked the Plan to pre-approve an extraction. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says the service at issue is not covered unless it is performed by a 
participating general dentist. Dental services performed by an oral surgeon are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an extraction have not been met. Specifically, the service at issue is not covered unless it is 
performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve 
an extraction (D7140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resuscitation bag (S8999). 
 
You asked the Plan to pre-approve a resuscitation bag. You say that this is medically necessary as a backup 
device. The Plan denied your request. The Plan says this item is not a covered benefit under Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the 
same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a resuscitation bag have been met. 
Specifically, this is not a benefit that is covered by Medicare or the Plan. Additionally, no medical records have 
been submitted to support the medical necessity of this device. Also of note, the records indicate that you have 
a backup ventilator that serves the same purpose as the requested equipment. Therefore, we decided that the 
Plan does not have to pre-approve a resuscitation bag (S8999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endodontics visit with an out-of-network provider. 
 
You asked the Plan to pre-approve an endodontics visit with an out-of-network provider. You say that the 
services are medically necessary. The Plan denied your request. The Plan says you are not covered for this 
service when seen by an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an endodontics visit with an out-of-network provider have not been met. Specifically, the requested 
provider in this case is not a network provider with the Plan. The Plan has network providers available who can 
provide the items/services at issue in this appeal. We found no exception that would require the Plan pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an endodontics 
visit with an out-of-network provider.
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 enrollee has reached the 100-day benefit limit for this admission. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from November 26, 
2021, through March 7, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period.  The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a 
hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 13, 
2021. 
 
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 provider did not bill as required as required by Medicare coding regulations. 
 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 imaging services provided to the enrollee on October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation provided 
supports the need for LTACH care. The Plan denied your request. The Plan says LTACH care is not medically 
necessary. The Plan says that the enrollee can safely receive the care needed in another setting, such as the 
current hospital. 
 
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 acute hypoxic respiratory failure due to exacerbation of 
chronic obstructive pulmonary disease. The record indicates that the enrollee continues to require 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 she is not currently receiving but that would be 
available at the LTACH facility.  
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional therapy visits are necessary for 
the enrollee to work on pain reduction, range of motion, and functional strength. The Plan denied your request. 
The Plan says the additional therapy requested is not medically necessary. The enrollee has had 25 visits to date 
and there is not sufficient documentation to support that the services needed require the skill of a therapist 
rather than what can be completed during the home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional therapy requested is not generally accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the health plan. The 
enrollee has had prior therapy, and the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment or that the services can only be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee should be 
able to transition to an independent home exercise program. The requested services are not part of a 
maintenance program and do not require the specialized skill, knowledge and judgment of a qualified therapist 
to establish, design and/or deliver a program to maintain the enrollees current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve twelve (12) additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (84443, 80061, 85025) provided October 12, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the service was performed for screening purposes only and is not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (84443, 
80061, 85025) provided October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PCD (CPT code E0675). 
 
You asked the Plan to pre-approve the PCD. You say that the PCD is necessary. The Plan denied your request. 
The Plan says this is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file 
and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have 
not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for 
preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they 
are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve the PCD (CPT code 
E0675).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Yervoy for the enrollee. 
 
You asked the Plan to pre-approve these drugs. You say that these drugs are medically necessary. The Plan 
denied your request. The Plan says that the clinical value and effectiveness of Opdivo combined with Yervoy 
as subsequent treatment in the setting of disease progression on prior PD-L1 therapy have not been 
demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 these drugs. Our reviewer says that 
these drugs are not medically reasonable and necessary for the enrollee. Opdivo and Yervoy are indicated for 
1st line therapy and are not FDA-approved for the enrollees diagnosis. The use of these drugs are not 
supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & 
Medicaid Services approved medical journal. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of these drugs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these drugs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdivo and Yervoy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bath-tub wall rails (CPT code(s): E0241 and E0242). 
 
You asked the Plan to pre-approve the bath-tub wall rails. You say that you are going to need the shower grab 
bars as part of post-op care. The Plan denied your request. The Plan says the requested service items are not 
covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the bath-tub wall rails (CPT code(s): E0241 and E0242).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 that 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 he/she is not currently 
receiving but that would be available at the LTACH facility. 
 
 
 
  
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 further pay for the surgery assistant services provided on August 13, 
2021. 
 
You asked the Plan to further pay for the services provided. You say that all services were medically necessary. 
The Plan denied your request. The Plan says the claim was processed at the allowable rate. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that the Plan has agreed to approve and pay CPT code 29980 based 
on the Medicare allowed amount. We found no exception that would require the Plan to further pay for the 
services at issue. Therefore, we decided that the Plan does not have to further pay for the surgery assistant 
services provided on August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair (K0814), provided on August 31, 
2021. 
 
You asked the Plan to pay for the power wheelchair. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the items were obtained from a provider who is not under contract with the 
health plan, is not certified for Medicare and was not authorized with the plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the power wheelchair (K0814), provided 
on August 31, 2021.