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

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the documentation does not reveal 
evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's high 
functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of 
a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF 
beyond the last covered date. The enrollee does not require skilled nursing or skilled therapy services (or a 
combination of these services) on a daily basis in a SNF. As a practical matter, the enrollee does not require the 
necessary services on 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery services provided on 
December 13, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you had this 
procedure done before and never paid a copayment. The Plan denied your request. The Plan says the proper 
copayment was applied for the service that was rendered. 
 
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 $250 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 You have been asked to pay a $250 copayment for the outpatient surgery services. The outpatient surgery 
services falls within the Outpatient surgery, including 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 copayment for the 
outpatient surgery services provided on December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of April 21, 2022, forward and could have been treated in a lesser 
restrictive setting. The enrollee was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, or delusions and was not showing any behaviors or aggression. The enrollee being cooperative 
and compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from February 25, 2021, 
to March 4, 2021, at diagnosis related group (DRG) 871. 
 
 You asked the Plan to pay for the inpatient hospital services at DRG 871. You say that these inpatient services 
were medically necessary. The Plan denied your request. The Plan says because the diagnosis of A41.9- Sepsis, 
unspecified organism, was not supported in the medical record, the DRG was revised to 193 (Simple 
Pneumonia and pleurisy with multiple comorbid conditions). 
 
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 principal diagnosis code A41.9, defined as Sepsis, 
unspecified organism. 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 at DRG 871. Our reviewer says that the diagnosis of A41.9- Sepsis, unspecified organism, is not 
supported in the medical record. Our physician reviewer found the enrollee was a then 75 year old female with 
a history of metastatic breast cancer. She presented to the Emergency Department with increasing shortness of 
breath. She was noted to have pancytopenia, left lung pneumonia and bilateral loculated pleural effusions. She 
required bi-level positive airway pressure and high flow oxygen therapy and antibiotics. There was no clinical 
or laboratory evidence of sepsis.  
 
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 inpatient hospital services provided from February 25, 2021, to March 4, 2021, at diagnosis related group 
(DRG) 871.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99211-25 x 15), neuromuscular reeducation 
(97112-GP,59 x 15), and electrical stimulation (G0283 x 15) provided from September 22, 2021, to November 
15, 2021. 
 
You asked the Plan to pay for Sanexas. You say that you were experiencing severe pain in your foot. You also 
say that you were looking for some relief. The Plan denied your request. The Plan says the services you 
received are not covered. 
 
Review of the file and publicly available records, we find that the physical therapy services at issue in this case 
were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Pennsylvania. The 
office visit at issue was billed with modifier 25, which is used to report a significant, separately identifiable 
Evaluation and Management (EM) service by the same physician or other qualified health care professional on 
the same day of a procedure or other service.  There is no documentation of any significant, separately identifiable evaluation unrelated to the treatment 
provided to the enrollee on this date of service. Therefore, we decided that the Plan does not have to pay for the 
office visit (99211-25 x 15), neuromuscular reeducation (97112-GP,59 x 15), and electrical stimulation (G0283 
x 15) provided from September 22, 2021, to November 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection services provided on 
November 24, 2021. 
 
You asked the Plan to waive the coinsurance for the injection services. You say that you were never told that 
there would be a 20% coinsurance payment for these services. The Plan denied your request. The Plan says the 
proper coinsurance was applied. 
 
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 20% 
coinsurance for In-network Drugs that usually arent self-administered by the patient and are injected or 
infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. The first 
injection total amount allowed was $1,835.89 with a coinsurance of $367.18 ($1,835.89 total amount x 20% 
coinsurance). The second injection total amount allowed was $70.41 with a coinsurance of $14.08 ($70.41 total 
amount x 20% coinsurance). The total coinsurance amount for both injections was $381.26 ($367.18 
coinsurance + $70.41 coinsurance). You have been asked to pay a $381.26 coinsurance for the injection services. The injection services falls within 
the Medicare Part B prescription drugs 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 the injection services provided on November 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that physical therapy is beneficial for the 
enrollee's healing and helps with her chronic pain. The Plan denied your request. The Plan says the requested 
physical therapy is not medically necessary. The medical notes from February do not show any new injuries, 
surgery, or recent trauma to justify ongoing physical therapy in the setting of no progress. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the Plan. The enrollee 
has had prior therapy, and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, or that the services can only be safely and 
effectively performed by a therapist, or by or under the supervision of a therapist. The enrollee can follow up 
with their treating physician due to additional complaints of back/hip/knee pain. The enrollee has been 
instructed on home management training. The requested services are not part of a maintenance program, and 
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the enrollees current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve twelve (12) additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation services provided on October 21, 
2020. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes remain 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 64635 is Destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint.  
 
 The CPT Code Manual definition of code Destruction by neurolytic agent, paravertebral facet joint nerve(s), 
with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in 
addition to code for primary procedure) 
 
We find that CPT code 64635 is not supported in the medical record. This code was billed with a -50 modifier, 
which indicates a bilateral service. The records do not show that the enrollee received bilateral services. 
Because the rules for coverage of the primary procedure have not been met, the add-on codes are not eligible 
for payment. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation services 
provided on October 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full IRF criteria . The Plan denied 
your request. The Plan says RF admission is not medically necessary because the enrollee can be managed at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is medically stable and does not need physician close supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. No rehab nursing needs have been identified or documented in the record. The enrollee 
does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF setting. IRF admission is not medically necessary based 
on medical stability and lack of medical complexity, and lack of rehab nursing needs. While the enrollee may 
benefit from therapy, the enrollee's rehab can be safely provided at a lower intensity and alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: 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 if you do not get admitted into SNF you would not 
be able to care for yourself. You have no support at home and are unable to transfer. It is unsafe for you to 
return home at this time. The Plan denied your request. The Plan says that you do not meet SNF 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 you 
qualify for SNF care. Our physician reviewer found you do have documented skilled nursing needs, in the form 
of daily wound care to sacral pressure wounds and intermittent wound care to an abdominal surgical 
wound. You do not have documented skilled therapy needs. Daily skilled services are required to establish a 
maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services rendered on 
November 5, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have 
financial responsibility because you did not authorize the transport. The Plan denied your request. The Plan 
says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for each one-way, Medicare-covered ground ambulance transport.  
 
 The enrollee has been asked to pay a $250 copayment for the ambulance services. The ambulance services fall 
within the Ambulance services benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the ambulance services rendered on November 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue transfer procedures provided on August 4, 2021. 
 
You asked the Plan to pay for tissue transfer 14041 and 15004. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because these codes 
are 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 14041 adjacent tissue transfer or rearrangement, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; defect 10.1 square centimeters to 
30.0 square centimeters. The CPT Code Manual definition of code 15004 is surgical preparation or creation of 
recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional 
release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 square centimeters or 1% of body area of infants and children. 
 
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 tissue transfer 14041 and 15004. Our reviewer says that these 
codes do not meet the criteria for payment. Our reviewer found the documentation describes undermining to 
create a flap in all directions, which would not be considered an adjacent tissue transfer or rearrangement. 
Therefore, code 14041 cannot be verified. The operative report does not support surgical preparation or 
creation of recipient site by excision to support code 15004. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tissue transfer 14041 and 15004 have not been met. Therefore, we decided that 
the Plan does not have to pay for tissue transfer procedures provided on August 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee went into the hospital for knee, ankle, 
and hip surgeries. When she goes home she is the primary caretaker for her husband. She needs inpatient 
rehabilitation because she is suffering from dysphagia, vertigo, hypertension, and is at a risk for falls and 
developing wound infections. The Plan denied your request. The Plan says IRF admission is not medically 
necessary because the enrollee can be managed at a lower level of care. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. No rehab nursing needs have been identified or documented in the record. The enrollee does not 
need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. IRF admission is not medically necessary based on 
medical stability and lack of medical complexity, and lack of rehab nursing needs. While the enrollee may 
benefit from therapy, the enrollee's rehab can be safely provided at a lower intensity and alternate 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 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.