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

 
We decided that the Plan has to approve SNF services after June 16, 2022. 
 
You asked the Plan to approve SNF care. You say that you need to extend your SNF stay. The Plan denied your 
request. The Plan says that the enrollee does not meet criteria for continued SNF care after June 16, 2022. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before June 16, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to approve SNF services after June 16, 2022.  
 
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 cannot walk and have no one to help you move 
around. You are also unable to get to outpatient physical therapy. The Plan denied your request. The Plan says 
an intensive rehabilitation program is not medically necessary. 
 
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee from 
January 5, 2022, to January 25, 2022. 
 
You asked the Plan to pay for out of network providers. You say that this claim should be paid. The Plan 
denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 out of network services provided to the enrollee 
from January 5, 2022, to January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the periodic oral evaluation (D0120), the 
dental cleaning (D1110), and the bitewing x-rays (D0274) provided on January 31, 2022. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share 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 if you choose to go to 
a dentist that does not participate in the network, you may pay more. The dentist can bill you for additional 
costs if what they charge is more than the maximum payable benefit amount for preventive services covered by 
the Plan.  
 
You have been asked to pay $96.82. The dentist billed the Plan in the amount of $208 for the dental services 
provided. The Plan paid the provider the allowable amount of $111.18, leaving a remaining balance of $96.82. 
The services in this case were rendered by an out-of-network provider. The Plan contract states that if you 
choose to go to a dentist that does not participate in the Plans network, you may pay more. The dentist can bill 
you for additional costs if what they charge is more than the maximum payable benefit amount for the 
preventive services covered by the Plan. 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 the periodic 
oral evaluation (D0120), the dental cleaning (D1110), and the bitewing x-rays (D0274) provided on  
January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percepta testing provided on December 20, 2021. 
 
You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says this testing is not 
medically necessary.  
The Plan follows Medicare rules. Medicare rules say that Percepta testing is covered for the indications 
established in the applicable LCD. 
 
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 testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a solitary pulmonary nodule and lymphadenopathy. The enrollee underwent bronchoscopy with 
Bronchoalveolar lavage. There is no documentation from the ordering provider that the results will be utilized 
to determine whether CT surveillance is appropriate in lieu of further invasive biopsies or surgical procedures, 
that the enrollee is monitored for malignancy, or that the test is ordered by physician certified in Percepta 
Certification and Training Registry (CTR). The enrollee does not meet all of the above LCD criteria for 
coverage of the requested Percepta testing. 
 
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 pre-approve Percepta testing provided on December 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxymorphone HCL ER. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxymorphone HCL ER.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services with secondary diagnosis code 
N39.0 and diagnosis related group (DRG) 493 provided from June 9, 2021, to June 16, 2021. 
 You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of the secondary diagnosis code N39.0 with DRG 493. The Plan denied your request. The Plan says the 
medical records do not support the billing of the secondary diagnosis code N39.0 with DRG 493. 
 
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 N39.0. 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. Our reviewer says that the medical records do not 
support the billing of the secondary diagnosis code N39.0 with DRG 493. Our physician reviewer found the 
enrollee was admitted and underwent fracture repair on June 9, 2021. While the physician also diagnosed the 
enrollee with a urinary tract infection, the clinical evidence did not support the diagnosis. The enrollee was 
noted to have a urine culture that showed greater than 100,000 cfu/mL of Klebsiella oxytoca. However, there 
was no documentation of urinary tract symptoms in the medical record. The enrollee denied fever, chills, 
sweats, abdominal pain, dysuria, increased urgency, or frequency with urination. In addition, the enrollee had a 
normal white blood count and remained afebrile throughout the admission. The review has determined that the 
medical records did not support the billing of the secondary diagnosis code N39.0 with DRG 493.  
 
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 with secondary diagnosis code N39.0 and diagnosis related group (DRG) 493 
provided from June 9, 2021, to June 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your record does not show that you require daily skilled nursing or 
skilled therapy in a SNF setting. 
 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 services. Our reviewer says that 
continued SNF services are not medically reasonable and necessary. You do not have documented skilled 
nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical 
matter, can be provided at a lower level of care. Our physician reviewer found that your condition does not 
meet Medicare criteria for continued SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on October 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing the claim denial. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
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 drug testing provided on October 29, 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 cardiac risk assessment genetic screening testing (81161, 
81403, 81404, 81405, 81406, 81407, 81408) provided April 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that attached documents supports the ICD and 
CPT's billed. Kindly review the documents and reprocess the claim towards payment. The Plan denied your 
request. The Plan says the diagnosis code does not substantiate service. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The documentation submitted indicates that the cardiovascular 
genetic screening panel was initiated by the laboratory and not by the treating physician. The Plan verified with 
the provider' s office that the genetic testing was not ordered by any provider in their office. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the cardiac risk assessment genetic screening 
testing (81161, 81403, 81404, 81405, 81406, 81407, 81408) provided April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the admission to 
LTACH. The Plan denied your request. The Plan says they denied transfer to LTACH because the enrollee is 
receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. The enrollee's 
status is critical and is receiving the necessary acute and critical care. The enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital, and there are no issues for which 
LTACH may offer a therapeutic advantage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to acute care on June 1, 2022, with sepsis and acute renal 
failure. He had cardiac arrest. Currently member was intubated. The mental status was unresponsive, weak 
decorticate posturing and weak corneal/gag. White blood cell count was increased to 14.2. On intravenous 
ceftriaxone. Respiratory status was minimal ventilator settings and poor neurologic status precludes SBT. 
Member is not stable to transfer to LTACH. 
 
There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is 
receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where he/she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ninety (90) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you do not have any 
other mode of transportation available to get to and from dialysis treatments. The Plan denied your request. The 
Plan says you have exhausted the maximum benefit of 100 one-way trips per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve ninety (90) additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 13, 2021. 
 
You asked the Plan to pay for the office visit. You say that you believed they took Medicare. The Plan denied 
your request. The Plan says services performed by a provider who has opted out of Medicare are not eligible 
for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TDAP vaccine provided on November 19, 2021. 
 
You asked the Plan to pay for preventative vaccines under Medicare Part B. You say that this bill should be 
covered by the Plan. The Plan denied your request. The Plan says this type of vaccine is not covered under 
Medicare Part B when administered preventatively. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventative 
vaccines under Medicare Part B. The Plan follows the same rules. Records do not show that you have been 
injured or directly exposed to any illness related to preventative vaccines under Medicare Part B. Therefore, we 
decided that the Plan does not have to pay for a TDAP vaccine provided on November 19, 2021.  
 
Benefits for preventative vaccines under Medicare Part B may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xolair. 
 
You asked the Plan to pre-approve Xolair. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Xolair. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Xolair is medically reasonable and necessary for the enrollee. The 
documentation does not support that the Xolair is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xolair have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xolair.