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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial of authorization for 
skilled nursing facility admission. The Plan denied your request. The Plan says based on Medicare guidelines 
and the information we have about the enrollee's condition the therapy needs can be met where they are now. 
 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 the enrollee has received physical therapy and was at a stand-by assist to contact 
guard assist level for functional mobility including gait to 260 feet. The enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. Our reviewer also found the enrollee does 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry (MS, 
MS/MS), analyte not elsewhere specified (83789) provided April 13, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please re-review the attached laboratory 
results.  Most in-network providers cannot perform such complex detailed drug testing services. The Plan 
denied your request. The Plan says this code is not separately reimbursed when billed for specimen validity 
testing on urine specimens utilized for drug 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, we have confirmed that code the 
laboratory service is an add-on code and has not been billed with an appropriate primary procedure code. 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 mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere 
specified (83789) provided April 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy visits provided from January 3, 2022, to 
January 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that the physical therapy was urgently needed to treat 
your acute hip and back injury. You say you were in immense pain and barely able to drive to the 
appointments. The Plan denied your request. The Plan says the rendering provider is out-of-network. The Plan 
determined you do not meet any of the exceptions for out-of-network coverage as listed in your contract. 
 
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 physical therapy visits provided from January 3, 
2022, to January 12, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to go to a skilled nursing facility (SNF). 
The Plan denied your request. The Plan says that the IRF care is not medically necessary, and the enrollee's 
needs can be met at a lower level of care such as at home with supervision and home health services. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows that you have active comorbidities which would continue to require 
close medical supervision on an inpatient basis. The evaluating therapists state that you would tolerate and 
benefit from intense therapy, thus IRF criteria have been and 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: Surgery
Decision: Partially Favorable

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

The definition of CPT 48999 is "Unlisted procedure, pancreas."

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 for CPT 48999. Our reviewer says that the provider reported CPT 48999 for a "Laparoscopy Pancreaticoduodenectomy (whipple)" procedure.  Operative report includes documentation to support  to confirm all criteria for a pancreaticoduodenectomy was performed, to include removal of the head of the pancreas, first part of the small intestine (duodenum),  gallbladder and the bile duct. In this case, there is no CPT code for a Laparoscopy Pancreaticoduodenectomy (whipple), and the appropriate code to report is an unlisted procedure.

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 services have been met. Therefore, we decided that the Plan has to pay for 48999. 

We also decided that the Plan does not have to pay for 44238.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

The definition of CPT 44238 is "Unlisted laparoscopy procedure, intestine (except rectum)."

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 for CPT 44238. Our reviewer says that the provider is reporting CPT 44238 for a "Laparoscopic braun enteroenterostomy" procedure (anastomosis between one part of the small bowel and another part of the small bowel). In this case, there is a more appropriate code to report for this service. Therefore CPT 44238 cannot be verified. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 44238 have not been met. Therefore, we decided that the Plan does not have to pay for 44238.

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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were advised by several doctors that receiving 
rehabilitation within the first six months of a stroke are vital to the success of regaining function and mobility 
and reducing the chances of future hospitalizations. The Plan denied your request. The Plan says that the IRF 
care is not medically necessary, and your needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows that you have active comorbidities and complications which would be 
expected to require close medical monitoring on inpatient basis. The evaluating therapists recommend intense 
therapy in more than one discipline, thus IRF criteria has been met and 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: 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 you have fallen twice and are not stable. The Plan 
denied your request. The Plan says you are without sufficiently complex medical needs. 
 
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 physician reviewer found 
that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation 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. You do not require treatment by multiple therapies in an intensive rehabilitation therapy 
program.  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 pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says settings that could 
be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our physician reviewer 
found that you have severe COPD and was recently hospitalized with pneumonia. Your arterial blood gas 
(ABG) was consistent with acute-on-chronic hypercarbic respiratory failure, although there is no ABG done as 
an outpatient while stable to confirm chronic carbon dioxide (CO2) retention. If you do have chronic CO2 
retention, you may benefit from BiPAP during sleep. However, Medicare does not cover a home ventilator 
when used as BiPAP. Therefore, a home ventilator is not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on February 18, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the physician depends on the hospital 
staff to obtain proper authorization. The Plan denied your request. The Plan says no prior authorization was 
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 did not pre-approve the 
subsequent nursing care. We found no exception that would require the Plan to pay for the subsequent nursing 
care. The records provided for review do not show that the subsequent nursing care was urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing care provided on February 
18, 2022, by an out-of-network (OON) provider.
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 medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for IRF admission. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation doesnt support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain her functional status.  You can receive further 
services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided by a 
participating provider on March 2, 2022. 
 
You asked the Plan to pay for an adjunctive pre-diagnostic test. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says D0431 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
adjunctive pre-diagnostic test (D0431) provided by a participating provider on March 2, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for Medicare Part B prescription drugs. We decided 
that the Plan does not have to waive the copayment for the Medicare-covered diagnostic radiology services.  
 
You asked the Plan to waive the copayment for a nuclear cardiology test provided on April 20, 2022.. You say 
that if you had known how expensive this test would have been, you would not have had it done. You cannot 
afford it. The Plan says that you were charged this cost sharing correctly. 
We decided that the Plan has to waive the copayment for Medicare Part B prescription drugs.  
 The Plan follows Medicare rules. Medicare rules say that the injection portion of this bill ($49.20) should be 
umbrellaed under the $195 copayment.  
 
The file shows that you have a medical indication for which Medicare will cover. Therefore, we decided that 
the Plan has to waive the copayment for Medicare Part B prescription drugs.  
 
We also decided that the Plan does not have to waive the copayment for the Medicare-covered diagnostic 
radiology services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $195 
copayment for Medicare-covered diagnostic radiology services. Therefore, we decided that the Plan does not 
have to waive the copayment for the Medicare-covered diagnostic radiology 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Apollo Full Hereditary CGx Panel provided on February 
15, 2022. 
 
You asked the Plan to pay for the Apollo Full Hereditary CGx Panel. You say that this test is payable by 
Medicare and was denied in error. The Plan denied your request. The Plan says there is no documentation by 
the provider of a clinical concern or how this test will directly impact treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare considers genetic testing medically 
necessary to establish a molecular diagnosis of an inheritable disease when the patient displays clinical features 
of an associated disease and the result of the test will directly impact the patients treatment.  In this case, the medical record from the provider who ordered this test does not indicate why this test was ordered.  There is 
nothing in the medical record describing the patients clinical symptoms that led to the ordering of this test.  
There is nothing in the medical records to describe how the results of the test would impact the patients 
treatment.  The sole medical record provided from the ordering physician is a simple medical wellness exam 
that does not detail any condition related to this genetic test. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Apollo Full Hereditary CGx Panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the Apollo Full Hereditary CGx Panel provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 24, 
2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a limited oral evaluation (D0140) is not covered by your dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on March 24, 2022.