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 SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that SNF 
care is not medically necessary for this enrollee. Our physician reviewer found the enrollee is at supervision 
level for transfers and ambulation. She is able to continue to improve function with repetitive exercise with 
non-skilled support. Daily skilled services are not 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of venous insufficiency using foam sclerosant, 
radiofrequency ablation and/or laser ablation. 
 
You asked the Plan to pre-approve the requested venous interventions. You say that this should be approved. 
The Plan denied your request. The Plan says the LCD criteria are not met.  
The Plan follows Medicare rules. Medicare rules say that vascular interventions may be covered when there are 
documented CEAP and VCSS scores and clear documentation of interference with daily living or quality of 
life. 
 
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 requested venous interventions. Our 
reviewer says that the requested procedures are not medically reasonable and necessary. Our physician 
reviewer found the case file does not contain documentation regarding signs and/or symptoms that interfere 
with activities of the enrollee's daily living and/or quality of life. In addition, the clinical documentation does 
not include CEAP clinical classification and VCSS scores. 
 
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 requested venous interventions have not been met. Therefore, we decided 
that the Plan does not have to pre-approve treatment of venous insufficiency using foam sclerosant, 
radiofrequency ablation and/or laser ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve RFA services. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that initial thermal radiofrequency ablation services 
will be covered after the patient has had at least two (2) medically reasonable and necessary diagnostic medial 
branch blocks. 
 
We looked at the file and Medicare rules. In this case, the record demonstrates only one medial branch block 
has been performed. Based on this information, we decided that Medicare rules for coverage of RFA services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint radiofrequency 
ablation (RFA) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care facility visit on February 9, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to the facility for a 
COVID-19 test and you were told the test would be free. You say you received a bill for $60. The Plan adjusted 
the claim to remove the $10 copayment for the COVID-19 test because it was assessed as a diagnostic test. 
You asked the Plan to waive the remaining $50 copayment. The Plan denied your request. The Plan says the 
copayment was applied correctly according to your contract. 
 
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 $50 
copayment for urgently needed services.  
 
You have been asked to pay a $50 copayment for an urgent care visit. The services at issue fall within the 
urgently needed 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 an urgent care facility visit on February 9, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care from February 6, 2022, to 
March 7, 2022. 
 You asked the Plan to pay for the SNF care. You say that these services should be covered. The Plan denied 
your request. The Plan says on these dates of service, the enrollee had no skilled nursing or therapy needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF care. Our reviewer says that SNF 
care from February 6, 2022, to March 7, 2022, was not medically necessary. Our physician reviewer found the 
enrollee no longer qualified for SNF coverage on these dates.  The enrollee did not have documented skilled 
nursing needs. The enrollees wound care was not complex. The enrollee did not have documented skilled 
therapy needs. The enrollee had reached a plateau in function. Daily skilled services were not required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs were custodial and could, 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) care from February 6, 2022, to March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 29, 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. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the laboratory services provided on 
January 29, 2021 have been met. We find that payment for the lab services is not supported in the medical 
record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the 
physicians intent that the test be performed prior to services taking place. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and administration 
you received at an outpatient hospital facility on November 11, 2021. 
 
You asked the Plan to waive the coinsurance for the chemotherapy drugs and administration. You say that you 
believe you had satisfied your deductible and out-of-pocket maximum for 2021, so there should be no cost 
sharing. The Plan denied your request. The Plan says you did meet your deductible for 2021, but you had not 
yet met your annual out-of-pocket maximum due to several claims being reprocessed. The Plan provided a 
detailed breakdown of cost sharing you have paid for 2021, and you had not yet met this maximum. 
 
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 chemotherapy drugs.  
 
You have been asked to pay 20% coinsurance for the chemotherapy drugs and administration. 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 coinsurance for chemotherapy drugs and administration you received at an 
outpatient hospital facility on November 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 12, 2021, to 
November 21, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that this was a readmission. There was no evidence that 
the second admission was not preventable. There were no records provided from the previous admission 
despite numerous requests. 
 
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. It should be noted that this appears to be a planned readmission for a specific, planned procedure.  This 
readmission was not done due to an unforeseen complication.   
 
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 the enrollee was admitted on November 12, 2021, and underwent elective single vessel 
coronary artery bypass grafting (saphenous vein graft to second obtuse marginal branch) with endoscopic right 
thigh vein harvest, mitral valve replacement with #27 Magna Ease bioprosthetic valve, placement of left atrial 
appendage clip and septal myomectomy. He tolerated the procedure well. He did have postoperative complete 
heart block and underwent implantation of dual chamber pacemaker November 17, 2021. He was ambulating 
without difficulty in the halls. He was initiated on warfarin and will require a minimum three-month course 
with goal INR 2.5-3.5 given his bioprosthetic mitral valve. The record showed that at the time of this second 
inpatient admission, the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier emergency room 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 November 12, 2021, to November 21, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is not medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 the enrollee is medically stable and does not need a physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs identified or 
documented.  At the enrollees current baseline dependency, they will not make a significant functional 
progress in the predicted period in an IRF. The enrollee does not need intensive therapies consisting of at least 
3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. While the 
enrollee may benefit from continued physical therapy, speech and occupational therapy, the enrollee's 
rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the straight-tip urine catheter you 
received from March 25, 2022, to April 25, 2022. 
 
You asked the Plan to reduce the coinsurance for the catheter. You say that the coding for this item appears to 
have changed and now you are being charged more than you were previously. The Plan denied your request. 
The Plan says you were charged this coinsurance 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 20% 
coinsurance for durable medical equipment, prosthetics, and related supplies.  
 
You have been asked to pay 20% coinsurance for the catheter. The catheter falls within the durable medical 
equipment, prosthetics, and related supplies benefit category. The allowed amount for each month of this item 
is $268.50.  That makes each month's coinsurance equal to $53.70 (268.50 X 20% = $53.70 per month.) This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This amount 
applies regardless of what you may have paid in the past. 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 reduce the 
coinsurance for the straight-tip urine catheter you received from March 25, 2022, to April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air conditioner purchased on April 7, 2021. 
 
You asked the Plan to pay for the air conditioner. You say that you would like to be reimbursed for this device. 
The Plan denied your request. The Plan says although their is a supplemental benefit for air conditioners that 
the Plan did offer in 2021, you were not enrolled in this program. 
 
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 pay for the air conditioner purchased on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80307 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for code 80307. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says the records do not include the results from this testing. 
 
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 80307 is  Drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service for service provided. 
 
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 code 80307. Our reviewer says that code 80307 is not 
supported in the medical record. Our reviewer found the laboratory report does not include a presumptive drug 
test, and therefore 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 code 80307 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 80307 billed for date of service March 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial inpatient nephrology consultation provided on December 18, 
2021. 
 
You asked the Plan to pay for the initial inpatient consultation. You say that this code should be paid as it was 
done by a physician of a different specialty. The Plan denied your request. The Plan says that procedure code 
99221 was billed on the same date of service as 90945 was billed by another nephrology provider. As these 
providers are of the same specialty, 99221 is considered to be part of the global package for 90945 and cannot 
be separately paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the surgical package of minor procedures usually 
include preoperative visits on the day of surgery. However, services of other physicians are not considered part 
of the surgical package unless there is a formal transfer of care to the other provider. 
 
We looked at the file and Medicare rules. The records show that the nephrologist at issue in this case is a 
physician in the hospital's nephrology department. The provider to whom code 90945 was reimbursed is a 
physician in the hospital's dialysis department. As these services were provided by two different physicians, 
albeit of the same specialty, this evaluation provided before dialysis would be included in the global package of 
the dialysis evaluation. The two providers are shown to have been managing different aspects of the enrollee's 
care. This consultation was not strictly a preoperative visit related to the later dialysis evaluation. As such, we 
find that the denial of payment in this case is not substantiated. Therefore, we decided that the Plan has to pay 
for the initial inpatient nephrology consultation provided on December 18, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is needed to optimize 
recovery. The Plan denied your request. The Plan says LTACH care 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 you were admitted to the acute care hospital with acute respiratory failure and recent 
COVID-19 infection, pneumonia, acute kidney injury, and pleural effusions treated with BiPAP, antibiotics, 
bronchodilators, bronchoscopy, and NGT placement complicated by ileus. Recent notes describe that you have 
new fever and antibiotics were extended along with antifungal therapy added on. You are tolerating high flow 
oxygen support. You appear to be somewhat unstable and require short-term additional acute care hospital 
services that can safely be completed at the current facility until more stable and more appropriate for a lower 
level of care. You do not require services at the LTACH that are not already available at the current 
facility. Transfer to LTACH is not medically necessary as you are not yet stable for transfer and as it would not be clinically advantageous. 
 
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.