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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and was at a minimal assist level for functional mobility including gait to 60 feet x 2. The 
enrollee does not require skilled nursing or therapy services on a daily basis.  The enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 you need antibiotics and wound care. 
The Plan denied your request. The Plan says you are receiving appropriate inpatient care at the current hospital. 
 
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 physician 
reviewer found that you were admitted to the acute care hospital  with intestinal obstruction due to cancer. You 
appear to be stable and gradually improving. You should only require short-term additional acute care services 
that can be safely provided at the current facility. 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 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the requested home ventilator is not medically reasonable and necessary. 
 
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 the home ventilator. Our physician 
reviewer found you do not have chronic obstructive pulmonary disease (COPD), thoracic restrictive disease, or 
neuromuscular disease, and therefore, do not have a diagnosis that qualifies for a ventilator by Medicare 
criteria. There is no arterial blood gas (ABG) documenting carbon dioxide (CO2) retention. If you do have 
obesity-hypoventilation syndrome, the appropriate treatment is continuous positive airway pressure (CPAP) or 
bilevel positive airway pressure (BiPAP). Medicare does not pay for a ventilator when used as BiPAP. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
October 21, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records submitted do not indicate that two separate services were performed. 
 
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 72110 is "Radiologic examination, spine, lumbosacral; 
minimum of 4 views." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that a review of the records shows a 
single 5 view lumbar spine series - CPT 72110 - was done on 10/21/21, and was interpreted. There was no 
additional or second lumbar spine series done on that date. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional imaging services provided to the enrollee on October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cervical and lumbar x-rays provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the x-rays. You say that you should be refunded your 
copayment because the x-rays did not address the issues you are having. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
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 in-network x-rays.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$50 copayment for the x-rays. X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 cervical and lumbar x-rays 
provided on November 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a knee arthroscopy provided on December 
13, 2021. 
 
You asked the Plan to waive the coinsurance for a knee arthroscopy. You say that you had the same surgery on 
your right leg and was not charged this amount. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 in-network outpatient surgery at an outpatient hospital.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$586.46, which is 20% coinsurance of the allowed amount for a knee arthroscopy ($2,932.29 allowed amount x 20% coinsurance = $586.46). A knee arthroscopy falls within the Outpatient Surgery and Other Medical 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 coinsurance for a knee arthroscopy provided on December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 3, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 15734: 
 
Muscle, myocutaneous, or fasciocutaneous flap; trunk 
 
CPT 32999: 
 
Unlisted procedure, lungs and pleura  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 15734, the 
operative report does not include enough detail of procedure to confirm a muscle, myocutaneous or 
fasciocutaneous flap was performed. In terms of CPT 32999, the operative report describes closure of a more 
complex procedure. When reporting an unlisted procedure, additional documentation should be included to 
support the unlisted procedure. In this case, this procedure code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on September 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says your 
condition has stabilized, and you are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued inpatient care from May 13, 2022, forward 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 were admitted to 
the acute inpatient psychiatric hospitalization with schizoaffective disorder and major neurocognitive disorder, 
unspecified with behavioral disturbance.  Based upon review the records, it was not expected that you would improve in a reasonable period of time for 
the dates in question as you did not have suicidal or homicidal ideation, auditory or visual hallucinations. You 
were compliant with treatment while not showing any acute threats to safety. It does not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question as you did not have dangerousness to self or others. 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for physical therapy services provided from 
June 10, 2021, to July 22, 2021. 
 
You asked the Plan to waive the cost share for physical therapy services. You say that these services were 
approved as in-network. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount.  
 
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 $40 
copayment for in-network physical therapy service.  
 
According to the Plan, the out-of-network deductible was removed, and the in-network $40 copayment was 
applied. You have been asked to pay up to a $40 copayment for each physical therapy service from June 10, 2021, to July 22, 2021. Physical therapy services fall within the Outpatient Rehabilitation 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 cost share for physical therapy services provided from June 
10, 2021, to July 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from February 13, 
2021, to February 17, 2021, billed with diagnosis related group (DRG) code 064. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 064. You say that this case was 
coded correctly, and the diagnosis is valid and correct according to the supporting documentation. The Plan 
denied your request. The Plan says DRG 064 is not supported as the diagnosis of Cerebral edema. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, G93.6, defined as 
Cerebral edema. 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 inpatient hospital 
services billed with DRG 064. Our reviewer says that the submitted DRG is not supported. Our physician 
reviewer found the enrollee presented with weakness and syncope and was found to have cerebrovascular 
accident (CVA). A magnetic resonance imaging of the head showed left parafalcine mass possibly representing 
meningioma. Our reviewer found that moderate regional vasogenic edema was found on imaging producing 
slight compression of superior aspect left lateral ventricle. However, there was no clinical abnormalities 
directly related to the edema, nor was there documented treatment for the edema independent of the treatment 
for the tumor to support using edema as a secondary diagnosis. Our physician reviewer also found that the 
provided medical records did not sufficiently support the secondary diagnosis of cerebral edema.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from February 13, 2021, to February 17, 2021, billed with diagnosis 
related group (DRG) code 064.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says unproven procedures are not 
covered by Medicare. 
 
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 pre-approve the requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. Therefore, the requested service is not considered 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
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. The Plan denied your request. The Plan says the 
enrollee is currently unstable for transfer. 
 
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 physician 
reviewer found the enrollee presented to the acute hospital with shortness of breath. She has been treated in the 
hospital with high flow supplemental oxygen, respiratory treatments, intravenous antibiotics and corticosteroids 
for pneumonia with respiratory failure and chronic interstitial lung disease. She continues to be dyspneic with 
exertion and remains on high flow nasal cannula oxygen, steroids and intravenous antibiotics. She is receiving 
an appropriate level of care in the present setting. The short-term acute care hospital can provide for all of her 
present inpatient care needs. The health plan has stated that continued care in the short-term acute care hospital 
will be covered. 
 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 27, 2021. 
 
You asked the Plan to pay for the services. You say that this should bep aid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 30903 (1 unit) remains not supported. 
 
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 30903 is "Control nasal hemorrhage, anterior, complex 
(extensive cautery and/or packing) any method." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the procedure report does not support 
an  anterior extensive cautery and/or packing any method. To cite the procedure: "Right nares was packed with 
cotton pledget soaked in Afrin. Patient with continued posterior phyarynx bleeding.  Patient;s right nares was 
packed with a 7.5 cm rapid Rhino partially soaked in tap water and partially soaked in TXA. There was no oral 
pharyngeal bleeding after.  Patient tolerated the procedure well; Right nares posterior epistaxis." There is a more appropriate code to report for service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on May 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgery services provided on February 24, 
2022, by an OON provider. 
 
You asked the Plan to pay for the outpatient surgery services. You say that you would like a retro authorization 
and you treated the enrollee out of medical necessity. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from the enrollee's primary care provider or 
an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 surgery services provided on 
February 24, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with metal crowns for teeth #2 and #11. 
 
You asked the Plan to pre-approve the crowns. You say that this is medically necessary. The Plan denied your 
request. The Plan says the teeth and gums must be healthy to cover this service. 
 
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. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the 
requested crowns are not medically reasonable or necessary. Our physician reviewer found the record provided 
is insufficient to determine that coverage is available for the requested services. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve white glass with metal crowns for teeth #2 and #11.