Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are easily winded and must rely on wheelchair 
and walker. The Plan denied your request. The Plan says request does not meet Medicare guidelines because 
you no longer require skilled services on a daily inpatient basis and the continuation of SNF is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the fundus photography (92250) provided 
on October 6, 2022. 
 
You asked the Plan to waive the copayment for the fundus photography. You say that you disagree with the 
amount you were reimbursed because in 2021 you were reimbursed the full amount that you paid out of pocket. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $10 
copayment for 1 eye exam every 12 months under the Routine Vision Services benefit category. 
 
 
 
 
 You have been asked to pay a $10 copayment for the fundus photography. This service falls within the Routine 
Vision Services benefit category. 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 waive the copayment for the fundus photography 
(92250) provided on October 6, 2022.
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 August 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. 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 August 28, 2022.
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 you are appealing the denial. The Plan denied your 
request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has had acute clinical and functional status change. Evaluating 
therapists recommend daily skilled therapy in a SNF. Documentation shows that the enrollee has made 
improvements in ambulation but still requiring physical assistance with bed mobility, toileting, brace 
management and lower body dressing thus daily skilled services on an inpatient basis in a SNF is medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your provider feels you would benefit from an IRF 
stay. The Plan denied your request. The Plan says you do not meet the Medicare guidelines for services in 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 that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood draw with travel expenses provided on December 14, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for blood draw with travel expenses. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
 
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 blood draw with travel expenses provided on 
December 14, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 You asked the Plan to pre-approve OON physical therapy services. You say that the enrollee has seen the 
provider previously and wants to continue. The Plan denied your request. The Plan says rules for coverage for 
OON services have not been met. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve OON physical therapy services. Our 
reviewer says that OON care is not medically reasonable and necessary in this case. Our physician reviewer 
found that the Plan has indicated that they have in-network providers. The requested therapy is standard and 
routinely available in many locations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OON physical therapy services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve physical therapy services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (procedure code 01992) provided to the enrollee on 
March 8, 2021. 
 
You asked the Plan to pay for the services. You say that this was billed with the appropriate modifier. The Plan 
denied your request. The Plan says that this is an incidental service to a primary procedure, which does not 
require separate reimbursement. 
 
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. The plan has not substantiated their denial in this case. The plan has not 
provided information on exactly what the primary procedure is in this case. There is no claim other than for 
CPT 01992 provided for review. Therefore, we decided that the Plan has to pay for anesthesia services 
(procedure code 01992) provided to the enrollee on March 8, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would greatly benefit from 
LTACH admission. The Plan denied your request. The Plan says the request 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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on December 2, 2021.  
You asked the Plan to pay for wound care. You say that the wound care was medically necessary. The Plan 
denied your request. The Plan says the wound care does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for wound care. Our reviewer says that the 
wound care does not meet the Medicare coverage criteria. Our physician reviewer found that the enrollee is an 
83-year-old with diagnoses of Type II diabetes and anemia, unspecified, noted to be complicating wound 
healing. The enrollee had unstageable partial thickness wounds on her right lateral foot, right fifth toe, and right 
fourth toe, as well as a stage 4 full thickness wound on her sacrum. The dressing treatment plan included skin 
prep and dressings. The limited medical records do not sufficiently support that wounds were debrided to the 
corresponding levels and sizes. The available records do not support the wound care services provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care have not been met. Therefore, we decided that the Plan does not 
have to pay for wound care provided on December 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drainage of peritoneal abscess or localized peritonitis, 
exclusive of appendiceal abscess, open provided to the enrollee on June 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 49020 is "Drainage of peritoneal abscess or localized 
peritonitis, exclusive of appendiceal abscess, open." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support the use of procedure code 49020-XS as the procedure 44143 was the reason for the opening of the 
abdomen in the first place. In this instance it would not be appropriate for the use of the procedure code. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open 
provided to the enrollee on June 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0482) provided on October 19, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was reported correctly. The Plan denied 
your request. The Plan says that this service is not supported as it was reported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the record shows that between 
15 and 21 drug classes were tested in this case, including alcohol biomarkers, amphetamines, benzodiazepines, 
buprenorphine, cannabinoids, fentanyls, heroin metabolite, methadone, methylenedioxyamphetamines, opiates, 
opioids and opiate analogs, oxycodone, phencyclidine, pregabalin, skeletal muscle relaxants, tapentadol and 
tramadol. Based on this information, we decided that Medicare rules for coverage of drug testing have been 
met. Therefore, we decided that the Plan has to pay for drug testing (G0482) provided on October 19, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve grab bars. 
 
You asked the Plan to pre-approve the bars. You say that this is medically necessary as the enrollee in a fragile 
state of health. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve grab bars.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the semi-electric hospital bed, (head and foot adjustment), with 
any type side rails, with mattress (E0260). 
 
You asked the Plan to pre-approve the hospital bed. You say that you serviced the enrollee with the hospital 
bed on September 3, 2019. You need authorization for E0260 for 9 months to complete rental billing cycle, or 
you will need to pick up the bed. The Plan denied your request. The Plan says that Medicare rules are limited to 
a 13-month rental period and 13 months have passed. Continued billing cannot be approved. 
 
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. the Plan has not provided any record that 13 months has been paid for E0260. 
No claims have been provided in the case file. The Plan has not substantiated their reason to continue to deny. 
Therefore, we decided that the Plan has to pre-approve the semi-electric hospital bed, (head and foot 
adjustment), with any type side rails, with mattress (E0260).  
 
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 an injection procedure for contrast knee arthrography or 
contrast enhanced CT/MRI knee arthrography provided to the enrollee on May 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says with the information they have, it cannot be determined how the enrollee came to the servicing 
provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27369 is "Injection procedure for contrast knee 
arthrography or contrast enhanced CT/MRI knee arthrography." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records provided 
does not include sufficient documentation to support that this service (27369) meets Medicare's criteria for 
billing and reimbursement consideration, therefore this service cannot be verified.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee 
arthrography provided to the enrollee on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary screening panel provided on August 27, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test was deemed necessary. The Plan denied 
your request. The Plan says the risk panel does not meet coverage criteria. 
 
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 test at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary screening panel 
provided on August 27, 2021.