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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your 
records do not show that you require skilled nursing or therapy services on a daily inpatient basis. The Plan 
states the services you require which include intermittent therapy can safely be received at a different setting, 
for example, home with home health, in residential care, or home with close follow-up with your doctor. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are 
ambulating more than one hundred (100) feet and tending to activities of daily living (ADLs) with minimal 
supervision. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs, custodial and intermittent, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 is not medically 
necessary. 
 
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 there is no need for physician supervision 3 times per week (at a minimum) for 
the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the 
rehabilitation needs can be safely met in an alternate and lower intensity 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99283) provided on June 
10, 2021. 
 
You asked the Plan to pay for the emergency department service. You say that you would like reconsideration 
because the member was seen by different providers. The Plan denied your request. The Plan says an edit exists 
between CPT codes 99283 and 99284. 
 
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 99283 
is a column II code to column I code 99284. 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 emergency department visit (99283) provided on June 10, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on June 3, 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 claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 you are medically stable it appears per information, does not need physical medicine 
and rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions.  
 You do not need intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per 
week with multidisciplinary approach to daily therapy in an IRF. You need routine physical therapy (PT) and 
occupational therapy (OT) but not an IRF. IRF admission is not medically necessary based on lack of medical 
complexity and lack of acute rehabilitation nursing needs found in the records. Document does not support the 
necessity for admission to an IRF. This determination is made based on PT and OT notes only. Your 
rehabilitation needs can be met safely at a lower intensity and alternate setting such as in a skilled nursing 
facility (SNF). 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayments for the outpatient hospital observation services, 
including a chest x-ray, CT scan, wound debridement procedure, IV infusion, and an MRI. We also decided 
that the Plan does not have to fully waive the copayments for outpatient hospital observation services. 
 
You asked the Plan to waive the copayments for the outpatient hospital observation services, including a chest 
x-ray, CT scan, wound debridement procedure, IV infusion, and an MRI. You say that you were apparently 
place in observation. You also say that the services should not be considered as outpatient. The Plan says that 
you have been charged the correct cost sharing amount. The Plan also says you were considered under 
observation during your stay. 
 
We decided that the Plan has to reduce the copayments for the outpatient hospital observation services, 
including a chest x-ray, CT scan, wound debridement procedure, IV infusion, and an MRI. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $90 copayment for an outpatient hospital observation visit, 
including all services received. 
 
The Plan says you must pay a total of $844.99 for a chest x-ray, CT scan, wound debridement procedure, IV 
infusion, and an MRI. Based on the Plan contract, however, you cannot be asked to pay more than a $90 
copayment for services received during each outpatient hospital observation visit. The Plan confirmed that your 
stay was considered an outpatient hospital observation, which includes all services received during that time. 
You cannot be charged for each service separately. Therefore, we decided that the Plan has to reduce the 
copayments for the outpatient hospital observation services, including a chest x-ray, CT scan, wound 
debridement procedure, IV infusion, and an MRI. 
 
We also decided that the Plan does not have to fully waive the copayments for outpatient hospital 
observation services. 
 
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 $90 
copayment for each outpatient hospital observation visit, including all services received.  
 
An outpatient hospital observation visit falls within the Outpatient Hospital Observation benefit category. 
Therefore, we decided that the Plan does not have to fully waive the copayment for an outpatient hospital 
observation visit. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve PT visits. You say that you need PT near your home because you broke 
your arm and cannot drive. You also say that you need care as soon as possible and have paid cash. The Plan 
denied your request. The Plan says the medical care you require can be provided by a network provider. 
 
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 items/services at issue in this appeal. The records provided for review do not 
show that the services at issue are urgent or emergent. We found no exception that would require the Plan to 
pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy (PT) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 14, 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 claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee braces (L1851 and L1832), provided on October 27, 
2021. 
 
You asked the Plan to pay for the knee braces. You say that the items are medically necessary. The Plan denied 
your request. The Plan says there is no documentation of knee pain, recent surgical procedure or injury of the 
right knee, and no evidence of joint laxity of physical examination. Additionally, there is no documentation 
why there is a medical need for two knee braces for the right knee. 
 
The Plan must follow Medicare rules.  
 
 
 Medicare rules say that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee 
joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both 
medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent 
injury to or a surgical procedure on the knee(s) or when knee instability is documented by examination of the 
beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer 
test).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee braces have not been met. Therefore, we decided that the Plan does not have to pay for the 
knee braces (L1851 and L1832), provided on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement amount for a u-step walker provided on 
October 28, 2021. 
 
You asked the Plan to increase the reimbursement amount for a u-step walker. You say that you were told you 
would be reimbursed 70% of the amount you paid for the walker. The Plan denied your request. The Plan says 
you have been reimbursed the correct amount. 
 
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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $36, which is 20% of the allowed amount for a u-step walker ($179.99 allowed 
amount x 20% coinsurance = $36). A u-step walker falls within the Durable Medical Equipment (DME) and 
Related Supplies benefit category. You were reimbursed a total of $143.99 ($179.99 allowed amount - $36 
coinsurance = $143.99). This means that you have been reimbursed 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 increase the reimbursement amount for a u-step walker 
provided on October 28, 2021.  
 
Please note that neither you nor the Plan are responsible for paying the balance bill. Please contact the 
provider about a refund for any amount you paid above the Medicare allowable amount for this walker. If the 
provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
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 stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program 
or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis rendered on September 23, 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 procedure code 81003 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 81003 (urinalysis without scope) and 81001 (urinalysis 
with scope). Code 81003 is a column II code with a modifier indicator of 1 when billed with column I code 
81001. Code 81003 was not billed with an appropriate modifier to allow for separate payment. Therefore, we 
decided that the Plan does not have to pay for the urinalysis rendered on September 23, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is not safe for you to return home at this time after 
a prolonged hospitalization. The Plan denied your request. The Plan says that the stay is not medically 
necessary based on SNF criteria. The Plan states your request does not show you have skilled nursing or 
therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states services you 
require can safely be received at a different setting, for example, home with home health, in residential care, or 
home with close follow-up with your doctor. 
 
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 physician reviewer 
found you do qualify for SNF coverage. You do not have documented skilled nursing needs. You do have 
documented skilled therapy needs. The documentation does not yet establish that you have reached a plateau in 
function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of 
your condition. Your care needs, as a practical matter, cannot 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 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with CPT codes 81229, 81415, 
81416, 81460 and 81465 and provided on May 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim has not been billed according to 
Medicare guidelines. 
 
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 codes 
81415, 81416, 81460 and 81465 are column II codes to column I code 81229. This claim has not been billed 
with an appropriate modifier to bypass the edit. Additionally, it is not appropriate to bill individual CPT codes 
for one panel. 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 laboratory services billed with CPT codes 81229, 81415, 
81416, 81460 and 81465 and provided on May 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from March 13, 2022, 
forward. 
 
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 stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee no longer qualifies for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollees wound care is not 
complex. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a 
plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from March 13, 2022, forward.