Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care from April 13, 2022, 
forward. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services at issue are medically 
necessary. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation you will require a greater than 2 midnight stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found at the time of admission, it was not reasonable to expect that two midnights 
in the hospital would be required. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care from April 13, 2022, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for short-latency somatosensory evoked potential study (95938) 
Visual evoked potential (VEP) (95930) provided on November 2, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic services. You say that the physician office failed to obtain 
authorization for the services rendered and as the facility who provided such services, should not be penalized. 
The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 short-latency somatosensory evoked potential 
study (95938) Visual evoked potential (VEP) (95930) provided on November 2, 2021 by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on August 12, 2021. 
 
You asked the Plan to pay for the testing services. You say that you were compliant with regulations for billing. 
The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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. The claim provided in this case was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the Guardant360 testing provided on August 12, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says that you no 
longer require skilled services. 
 
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. 
 
Continued SNF services beyond April 13, 2022, were requested. 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 continued services. Our physician reviewer found that you do have documented skilled 
nursing needs in the form of daily wound care in a hard to reach/see area. You do not have documented skilled 
therapy needs. Daily skilled services are required to establish a maintenance program and/or to prevent 
deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services 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 
continued skilled nursing facility (SNF) services.  
 
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 the outpatient office visit (99203) tangential biopsies (11102) 
Destruction of premalignant lesions (actinic keratoses) (17000, 17003) each separate/additional lesion (List 
separately in addition to code for primary procedure) (11103) provided on December 17, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that please find the attached medical records to support 
the charges. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) tangential 
biopsies (11102) Destruction of premalignant lesions (actinic keratoses) (17000, 17003) each 
separate/additional lesion (List separately in addition to code for primary procedure) (11103) provided on 
December 17, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for lab services and diagnostic procedures/tests performed in an outpatient hospital facility. 
 You have been asked to pay a $30 copayment for the laboratory services provided in an outpatient hospital 
facility. 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 laboratory services provided on  
December 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional outpatient physical therapy (PT) services 
(97139 x6). 
 
You asked the Plan to pre-approve the additional outpatient PT services. You say that you would like to appeal 
these services. The Plan denied your request. The Plan says these visits are not medically necessary. The Plan 
also says that the documentation does not support that you require the skills of a licensed physical therapist to 
continue with further left hand/thumb strengthening and to maintain your near normal left-hand function. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the outpatient PT services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the additional requested 6 therapy visits are generally 
not accepted as specific and effective therapy for your condition beyond what was approved by the Plan. You 
have had prior therapy and the documentation does not reveal that you require the unique skills of a 
professional therapist to safely and effectively provide treatment, or that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. Our reviewer found that 
you rate your progress at 70% in terms of your motion and strength in your left hand/thumb. You are compliant 
in a home exercise program. Our physician reviewer also found that the requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient PT services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 6 additional outpatient physical therapy (PT) services (97139 x6).
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 patient had a total knee replacement on April 13, 
2022, and requires rehab, and she has nowhere to go to get assistance. The Plan denied your request. The Plan 
says IRF is not medically necessary and the patient can be managed at a lower level of 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. Our physician reviewer found the patient does not require the intensity of services provided at an 
IRF.  Specifically, the patient is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  The patient's care needs can be met 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care as of April 17, 2022. 
 
You asked the Plan to pre-approve SNF care as of April 17, 2022.. You say that the patient is not ready to come 
home. You said that nhe needs more therapy time because she keeps falling and can't walk well. The Plan 
denied your request. The Plan says continued SNF care as of April 17, 2022, 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 as of April 17, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not 
have documented skilled nursing needs.  The patient does not have documented skilled therapy needs.  The 
patient appears to be functioning at/near her baseline.  Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of her condition.  The patient's 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 as of April 17, 2022. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care as of April 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 3, 2021 to March 25, 2021. 
 You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the provider billed the claim statement for 
more than a 30 day period. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was billed for a period of care that was more than 30 days. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from March 3, 2021 to March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lipid panel testing provided on November 24, 2021. 
 
You asked the Plan to pay for lipid panel testing. You say that you did not know there was any maximum 
amount for this test. The Plan denied your request. The Plan says the denial of payment for this test is correct, 
because this test is only covered once every 5 years and you previously had a covered lipid panel on November 
12, 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that lipid panel screening testing is covered once 
every 5 years.  
 
We looked at the file and Medicare rules. You previously had covered lipid panel screening testing on 
November 12, 2020, so 5 years had not passed before this testing was provided. Based on this information, we 
decided that Medicare rules for coverage of lipid panel testing have not been met. Therefore, we decided that 
the Plan does not have to pay for lipid panel testing provided on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 13, 2021, and August 18, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you agreed 
with the ambulance personnel that the enrollee did not need to be transported to the hospital. You also say that 
had you been advised the enrollee needed to be transported to the hospital, you would have done so 
immediately. The Plan denied your request. The Plan says these services were processed correctly. The Plan 
also says that the enrollee does not have non-transport ambulance coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 13, 2021 to August 18, 2021. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment with no transport (A0998) provided on August 13, 2021, and August 18, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services to be provided by your niece. 
 
You asked the Plan to pre-approve personal care services to be provided by your niece. You say that your niece 
has been taking care of you for years since you cannot take care of yourself and walk on your own. The Plan 
denied your request. The Plan says personal care services is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that charges imposed by immediate relatives of the 
patient or members of the patients household are expenses that constitute charges by immediate relatives of 
the beneficiary or by members of their household are excluded from coverage. 
 
We looked at the file and Medicare rules. Medicare excludes coverage for expenses that constitute charges by 
immediate relatives of the beneficiary or by members of their household. Based on this information, we 
decided that Medicare rules for coverage of personal care services to be provided by your niece have not been met. Therefore, we decided that the Plan does not have to pre-approve personal care services to be provided by 
your niece.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service December 
15, 2021. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service December 15, 
2021.
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 IRF is appropriate for you. The Plan denied your 
request. The Plan says your medical condition requires further care in the acute care hospital. You are not ready 
for transfer at this time. 
 
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 do not require the intensity of services provided at an IRF.   Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on June 24, 2021. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this exceeds the MUE.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical 
care services (99291) provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis (L3916) provided September 7, 2021. 
 
You asked the Plan to pay for the orthosis. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says there is evidence of misrepresented 
services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis (L3916) 
provided September 7, 2021.