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 enrollee needs therapy for strengthening. The 
Plan denied your request. The Plan says the denial of authorization for SNF care is correct. 
 
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 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. 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 skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on May 12, 2021. 
  You asked the Plan to pay for the physical therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the records do not support 
the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on May 12, 2021.
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 LTACH is the safest and most efficient 
level of care. The Plan denied your request. The Plan says the denial of authorization for LTACH care is 
correct. 
 
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 appears to be gradually improving and only short-term acute care 
services are needed that can be safely administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. Transfer to a lower level of care may be 
considered when treatment has completed. 
 
 
 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for continued inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the enrollee is at the clinical and functional pre-admission baseline. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. According to the documentation, she was not participating with 
therapy and therefore did not qualify for skilled nursing rehab. Her discharge plan was currently long-term care 
and the case manager was working with her family to transition to a long-term care facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for continued inpatient hospital 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia service (99100) provided on April 15, 
2021. 
 
You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because code 99100 is 
always bundled for payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled for payment.  
 
We looked at the file and Medicare rules. This code is always bundled for payment and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been 
met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided 
on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded as G0500 and 99153 provided 
from May 18, 2021, to May 20, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that these claims should be reprocessed based 
on the medical records. The Plan denied your request. The Plan says the documentation does not support the 
services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code G0500 is moderate sedation services provided by the 
same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 
sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 
years or older (additional time may be reported with 99153, as appropriate). The CPT Code Manual definition 
of code 99153 is Moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence 
of an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service). 
 
We find that CPT codes G0500 and 99153 are not supported in the medical record. Specifically, the 
documentation provided does not include evidence that an independent trained observer was present while ethe 
services were rendered. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded as G0500 and 99153 provided from May 18, 2021, to May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional epidural injections (64484 x 2). 
 
You asked the Plan to pre-approve additional epidural injections. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says additional epidural injections beyond what has already 
been approved are not allowed by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two epidural injections may be 
performed at a single session. 
 
We looked at the file and Medicare rules. In this case, the requested epidural injections exceed the benefit limit 
as defined by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
additional epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional epidural injections (64484 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endovenous ablation therapy for the enrollee. 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that this treatment is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 endovenous 
ablation therapy. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation does not meet the coverage 
criteria. Specifically, coverage requires that the veins to be symptomatic.  It is not possible to attribute lower 
extremity symptoms to varicose veins nor the appropriateness of saphenous vein ablation, particularly in a 71-
year-old woman, without an assessment of arterial perfusion.  In this case there is no documentation of the 
degree of arterial perfusion.  Additionally, coverage criteria require there be recurrent episodes of superficial 
phlebitis.  In this case there is documentation that this was her first episode. Furthermore, coverage requires 
documentation that the patient?s symptoms be activity limiting.  This cannot be determined in the acute phase 
of the phlebitic episode as symptoms related to this are likely transient.  There is no documentation that the 
patient was having lifestyle limiting symptoms due to her varicose veins prior to the episode of phlebitis. 
Additionally, coverage requires documentation of a concerted, 3-month, trial of conservative therapy.  There is 
no documentation that this has been attempted. The venous duplex report does not describe other diameters 
throughout the length of the greater saphenous vein therefore Medicare coverage criteria are not met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70544) provided to the 
enrollee on May 19, 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 appropriate modifier was not 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 code 70544 is "Magnetic resonance angiography, head; 
without contrast material(s)." 
 
We find that CPT code 70544 is not supported in the medical record. Specifically, this code cannot be billed 
separately without the appropriate modifier. 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 
imaging services (procedure code 70544) provided to the enrollee on May 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from  
July 7, 2020 to July 29, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like these services reprocessed as 
you feel they denied in error. The Plan denied your request. The Plan says this claim is billed with incorrect 
information and requires a corrected claim. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
includes multiple incorrect revenue codes that do not correspond with the home health services as rendered. 
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee 
from July 7, 2020 to July 29, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the knee-ankle-foot orthosis (KAFO) provided on January 18, 2021. 
 
You asked the Plan to pay for the KAFO. You say that you were not aware that you would require prior 
authorization for this item. The Plan denied your request. The Plan says that authorization was not requested 
until after the item was provided. As such, the denial is correct. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided with the KAFO by a contract provider. The file does not show that the Plan provided notice 
that the KAFO would not be covered. Although prior authorization is required, the contract provider is 
expected to verify coverage and fulfill authorization requirements at the time of service. Under Medicare rules, 
this means the KAFO is considered approved by the Plan. Therefore, we decided that the Plan has to pay for 
the knee-ankle-foot orthosis (KAFO) provided on January 18, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from May 20, 
2021, to May 26, 2021.  
 
You asked the Plan to pay for acute inpatient hospital care. You say that this claim should be paid. The Plan 
denied your request. The Plan says that Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the medical records show the went to the emergency room and was found to have a urinary 
tract infection and significant leukocytosis with left shift, no symptoms and was admitted. She was started on 
IV antibiotics, IV fluids 75 ml/hr. Vitals normal. Urine culture ordered, physical therapy and infectious disease 
consulted. The member complained of back pain, x-ray sowed 2 new compression fractures of the spine, 
member had L1 kyphoplasty 3/9/21 and plan for another kyphoplasty during admission. Urine culture was 
negative, IV antibiotics discontinued. Member declined going to rehab and discharged home with home health. 
The review has determined that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have 
been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided to the 
enrollee from May 20, 2021, to May 26, 2021.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on December 22, 
2020. 
You asked the Plan to pay for an emergency room visit. You say that this is supported in the records. The Plan 
denied your request. The Plan says documentation of this service has not been submitted. 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 rules also say that the provider, supplier, or 
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine 
whether payment is due and the amount of payment. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, the submitted medical record 
consists of a single page with patient identifying information and the date of admission. There is not 
documentation of any services provided. Based on this information, we decided that Medicare rules for 
coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to 
pay for an emergency room visit (99285) provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit with a specialist (99213), an 
eye examination (92083), and computerized ophthalmic diagnostic imaging (92133) rendered from  
July 6, 2021, to July 9, 2021. 
 
You asked the Plan to waive the deductible for an office visit with a specialist, an eye examination, and 
computerized ophthalmic diagnostic imaging. You say that this charge belongs to someone else. You also say 
that you had a complete eye exam June 6, 2021 and you paid $80, and that has been closed. The Plan denied 
your request. The Plan says you were 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). The Plan contract says that there is a $500 deductible for all items 
and services except those specifically excluded by the Plan contract.  You have been asked to pay a $176.61 deductible for an office visit with a specialist, an eye examination, and 
computerized ophthalmic diagnostic imaging. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $500 deductible, which applies to Vision Care and Physician/Practitioner Services, 
Including Doctor?s Office Visits. 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 that had not been met at the time an office 
visit with a specialist, an eye examination, and computerized ophthalmic diagnostic imaging was received from 
July 6, 2021 to July 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an 
office visit with a specialist (99213), an eye examination (92083), and computerized ophthalmic diagnostic 
imaging (92133) rendered from July 6, 2021, to July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on 
June 3, 2021. 
 
You asked the Plan to pay for these services. 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 medical services provided to the 
enrollee on June 3, 2021.