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 member's nursing, medical management, and rehabilitation needs 
do not require an interdisciplinary team approach to delivery of rehabilitation 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 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 rehab nursing needs identified or documented in the record. The enrollee will 
not make a significant functional recovery in a predicted period of time in an IRF. The enrollee does not need 3 
hours a day five days a week of IRF therapies with interdisciplinary management and the enrollee's rehab needs 
can be met in an alternate and lower 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: 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 enrollee meets the full criteria for an IRF stay. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 
an IRF. 
 
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 the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. The enrollee has no rehabilitation nursing needs 
identified or documented in the record. At the current level of function, the enrollee does not need 3 hours a 
day five days a week of IRF therapies with interdisciplinary management and the enrollee's rehabilitation needs 
can be met in an alternate and lower setting such as in an SNF. She needs routine physical therapy and 
occupational therapy which can be provided in a lower intensity setting such as in a skilled nursing facility. The 
complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The documentation does not support the necessity 
for admission to an IRF.  
 
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 pay for the drugs provided on November 10, 2021. 
 
You asked the Plan to pay for the services provided. You say that a compounded drug was administered to the 
enrollee. The Plan denied your request. The Plan says the billed codes cannot be 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. 
 We looked at the file and the rules. The multiple drug codes reported on the claim refer to a compounded drug. 
The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this 
compounded drug was not billed properly, payment cannot be made. Therefore, we decided that the Plan does 
not have to pay for the drugs provided on November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554) 
and supplies (K05443). 
 
You asked the Plan to pre-approve a CGM receiver and supplies. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the member does not use insulin with at least three daily injections 
and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM 
receiver and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) receiver (K0554) and supplies (K05443).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on September 23, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (70450) provided on September 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services you require can safely be received in 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 that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that the services you require to get stronger you 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 care. Our reviewer says that SNF 
care is medically reasonable and necessary. Documentation clearly supports the need for skilled nursing 
services. You have had a complicated hospital course and would be expected to continue to require close 
monitoring of cardiopulmonary status which requires the specialized skill, knowledge of a professional nurse. 
Clinical documentation supports the need for skilled therapy services. Impairments in functional mobility and 
activities of daily living are documented and you will require close monitoring during rehabilitation by a 
skilled therapist to monitor any cardiopulmonary decompensation. The evaluating occupational and physical 
therapist recommend you have skilled therapy sessions 5 days per week. While you require contact guard assist 
and supervision for mobility and self-care tasks, your level of supervision requires skill of licensed therapist. 
As a practical matter, you will benefit from daily skilled nursing and therapy services on an inpatient basis in a 
skilled nursing facility. Our physician reviewer found that your condition meets Medicare criteria for SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 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 physical therapy services provided from November 1, 2021, 
to November 29, 2021. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim 
was not billed with the appropriate coding.  
The Plan must follow Medicare rules. Medicare rules say that discipline-specific evaluation and re-evaluation 
codes are always reported with the modifier for the associated discipline. Claims that do not meet this condition 
are returned to the provider. 
 
We looked at the file and Medicare rules. Code 97161 was not billed with code modifier -GP as is required by 
Medicare coding guidelines; therefore, this claim is returned to the provider for correction. Based on this 
information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for physical therapy services provided from November 1, 2021, to 
November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle placement rendered on November 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 36000 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 36000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the needle 
placement rendered on November 5, 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 criteria for admission to the LTACH 
have not been met. The enrollee's medical needs are being met in the current acute setting. The Plan denied 
your request. The Plan says the enrollee needs to be in an LTACH for additional help. 
 
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 appears to be more stable and improving with current treatment and 
should only require short-term additional acute care services that can safely be administered at the current 
facility until appropriate for a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. There are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Transfer to LTACH will be considered not 
medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be 
considered when treatment has completed.  
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 pay for the outpatient clinic visit for COVID-19 specimen collection 
rendered on June 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the APC payment. 
 
The Plan must follow Medicare rules. The rules say that the OPPS status indicator identifies whether the 
service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or 
packaged. 
 
We looked at the file and Medicare rules. Billed procedure code C9803 has an OPPS SI of S and is separately 
payable only when not billed with a HCPCS code with the same SI. The file shows that code C9803 was billed 
with code 99283 and is therefore not separately payable. Therefore, we decided that the Plan does not have to 
pay for the outpatient clinic visit for COVID-19 specimen collection rendered on June 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that it is essential to provide the enrollee with 
non-invasive ventilation therapy to aid in improving their daily quality of life, decrease her shortness of breath, 
and allow the enrollee more time at home with their family. The Plan denied your request. The Plan says the 
request for a home mechanical ventilator set in AVAPS mode with Auto-EPAP (AE) that could be delivered by 
BiPAP is not covered. 
 
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 ventilator. Our physician reviewer found a home ventilator is not medically necessary.  This patient has HFrEF, severe pulmonary 
hypertension, and was recently hospitalized with pulmonary edema. The partial pressure of carbon dioxide 
(PaCO2) was increased to 62.5 and came down to near normal with bilevel positive airway pressure (BiPAP). 
There is no diagnosis for which Medicare covers a ventilator (COPD, thoracic restrictive disease, 
neuromuscular disease). Medicare does not cover a 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 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on October 8, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician.  
 
 
 
 We looked at the file and Medicare rules. The file shows that a physician in the same group practice billed 
procedure code 99285 (ER services) for the same date of service. The services billed under code 99283 are not 
separately payable. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) 
services rendered on October 8, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 26, 2021, to 
March 28, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service was medically necessary. 
The Plan denied your request. The Plan says that the service was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found physician reasonably expected that the patient's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 26, 2021, to March 28, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically reasonable and necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 a home ventilator. Our reviewer says 
that this device is not medically reasonable and necessary. Our physician reviewer found a home ventilator is 
not medically necessary. This patient has COPD with stage IV adenocarcinoma of the lung. The patient was 
recently admitted with a combination of COPD exacerbation and acute heart failure with pleural effusions.  The 
PaCO2 was elevated.  There is no arterial blood gas test done while stable as an outpatient.  There is no 
documented failure of bi-level positive airway pressure (BiPAP) device, with or without average volume-assured pressure support mode, as an outpatient. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 rendered on March 29, 2021.