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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you are close to your baseline level of function and do not have active 
medical conditions that require regular nursing or physician oversight. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure, congestive 
heart failure, renal failure, and Clostridium difficile colitis. Your medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 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. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation from a hospital to a nursing home 
provided on December 23, 2021. 
 
You asked the Plan to pay for the ambulance transportation. You say that this claim should be payable because 
the enrollee was not an inpatient at the time. This transport was for after discharge from the hospital. The Plan 
denied your request. The Plan says that there is an inpatient hospital claim that shows that the enrollee was not 
discharged until December 24, 2021. This means that Part A must cover the ambulance trip. 
 
The Plan must follow Medicare rules. Medicare rules say that if an enrollee is an inpatient of a facility, then 
Part A covers the transportation as part of the facility payment. However, transfer from one facility to another 
is payable by Medicare Part B as the enrollee is not an inpatient at either facility.  
 
In this case, though the inpatient claim includes December 24, 2021, it is noted that the discharge time is 
logged at 12:47AM. The ambulance record clearly shows that this transportation was provided after discharge 
from the facility, before midnight. The inpatient claim does not include any ambulance transportation. The 
evidence supports that the enrollee was not an inpatient at any facility at the time this transport was performed, 
meaning Part B payment can be made. Therefore, we decided that the Plan has to pay for the ambulance 
transportation from a hospital to a nursing home provided on December 23, 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 IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says medical necessity 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (CPT code S9500) provided from 
November 7, 2021, through November 11, 2021. 
 
You asked the Plan to pay for the home infusion therapy. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not covered as 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. 
 
Medicare guidance says status code I Not valid for Medicare purposes. Medicare uses another code for 
reporting of and payment for these services. Therefore, we decided that the Plan does not have to pay for the 
home infusion therapy (CPT code S9500) provided from November 7, 2021, through November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
required documentation has not been received. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage for any 
service, the information submitted must corroborate the documentation in the beneficiary's medical 
documentation. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the 
requested services are necessary. The Plan made multiple attempts to obtain additional information with no 
success. Based on this information, we decided that the rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve epidural steroid injections.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam therapy (PBT.) 
 
You asked the Plan to pre-approve PBT. You say that the records provided support the need for PBRT. The 
Plan denied your request. The Plan says that guidelines do not support the routine use of PBRT for the 
enrollee's cancer type. The Plan says that it has not been shown that the enrollee's cancer type has responded 
well to PBRT. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of PBT in Group 2 is limited to providers 
who have demonstrated experience in data collection and analysis with a history of publication on the peer-
reviewed medical literature. Prostate cancer without distant metastases is listed under Group 2. 
 
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 PBT. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the 
documentation supports that the requested PBT is from a provider who has demonstrated experience in data 
collection and analysis with a history of publication in the peer-reviewed medical literature. Specifically, 
https://pubmed.ncbi.nlm.nih.gov/?term=mihalcik+s+prostate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have been met. Therefore, we decided that the Plan has to pre-approve 
proton beam therapy (PBT.)  
 
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 pay for inpatient rehabilitation services provided on December 24, 
2020, to January 9, 2021by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient rehabilitation services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says services provided out-of-network are not covered. The 
Plan says that prior authorization was not obtained. 
 
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 inpatient 
rehabilitation services provided on December 24, 2020, to January 9, 2021by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on December 7, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that this service was necessary following your 
cataract surgery. The Plan denied your request. The Plan says you had a previous refraction on May 17, 2021, 
and November 30, 2021. The Plan covers a maximum of two eye refractions per year. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury. However, the Plan offers a vision and eyewear benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 
two eye refractions per year. 
 
We looked at the file and the Plan's rules. The record shows that you have had two other eye refractions in 
2021 which were covered by the Plan. Based on this information, we decided that the Plan's rules for coverage 
of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye 
refraction (92015) provided on December 7, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for outpatient physical therapy services (97110, 97112, 97530) provided 
from June 8, 2021, to July 5, 2021. 
 
You asked the Plan to pay for physical therapy. You say that these services were billed correctly and are 
supported in the record. The Plan denied your request. The Plan says that these services should be coded with 
G0151 because these services were performed in a home health setting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code the outpatient physical therapy services is supported in the medical record. Specifically, 
these were outpatient therapy services provided in the enrollees home and were not rendered or billed under a 
home health plan of care. Based on this information, we decided that Medicare rules for coverage of physical 
therapy have been met. Therefore, we decided that the Plan has to pay for outpatient physical therapy services 
(97110, 97112, 97530) provided from June 8, 2021, to July 5, 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
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 the 
service is medically necessary. Our physician reviewer found per clinical documentation, skilled nursing 
services are required to help assist with wound care and monitor comorbidities. Skilled therapy is also required 
as you have documented new deficits in mobility and self-care. Your care team recommends skilled therapy 
and nursing in a skilled nursing facility with supporting evidence of care needs. As a practical matter, you 
require daily skilled nursing and therapy services that would be best suited on an inpatient basis in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, abdominal, real time with image 
documentation; limited (eg, single organ, quadrant, follow-up (CPT code 76705) provided on January 28, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed.  
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the ultrasound have not been met. NCCI Procedure to Procedure 
(PTP) edit exists between 76705-26 and 93976. This PTP edit has a modifier indicator of 1, modifiers 
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code 
edit. Therefore, we decided that the Plan does not have to pay for the ultrasound, abdominal, real time with 
image documentation; limited (eg, single organ, quadrant, follow-up (CPT code 76705) provided on January 
28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Confirm MDX test provided to the enrollee on December 
20, 2021.  
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for the requested, and it is therefore not approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the first biopsy was from 12/20/21, resulting in benign histology. ConfirmMDx was requested. However, 
the provided documentation did not clearly show the patient meeting criteria to justify this test. However, the 
ConfirmMDx was ordered on the same day as the biopsy and, therefore, the biopsy had not been resulted at the 
time of ordering this test to meet criteria.  
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Confirm MDX test provided to the enrollee on December 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided on 
December 28, 2021. 
 
You asked the Plan to pay for the abdominal ultrasound. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not covered as 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, we have confirmed that code 76705 
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 the 
abdominal ultrasound (CPT code 76705) provided on December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 81455) provided on August 
4, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 81455 (1 Unit) 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an On Campus-Outpatient Hospital POS 22. Also, the laboratory results 
submitted indicate the specimen was collected on August 4, 2021, and received by the lab on August 7, 2021; 
therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional 
information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory 
service (CPT code 81455) provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Full Cardiology Genetic Panel provided to the enrollee on 
September 22, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says screening genetic testing is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that as the patient is already at high risk based on their history of myocardial infarction (MI), treatment 
would not significantly change based on the results of a genetic test. Therefore, this request for genetic testing 
will be considered not medically necessary for this patient.  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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a Full Cardiology Genetic Panel provided to the enrollee on September 22, 2021.