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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services billed with Patient-
Driven Payment Model (PDPM) score JHXF1 x19 days provided from June 5, 2020 to June 24, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan follows Medicare rules. Medicare rules say that SNF services are paid based on a PDPM score. 
 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 SNF services. Our reviewer says that the 
documentation does not support that billing of PDPM score JHXF1 x19 days. Our physician reviewer found the 
enrollee had a diagnosis of unspecified convulsions. The enrollee was admitted to the SNF with deconditioning 
and ongoing acute metabolic encephalopathy. The documentation does not support SLP comorbidity of 
Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke coded on the MDS as an active 
disease during the look back period. Therefore, the PDPM score billed is not supported by the documentation. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services billed with Patient-Driven Payment Model 
(PDPM) score JHXF1 x19 days provided from June 5, 2020 to June 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial observation care (99218) provided February 25, 
2021. 
 
You asked the Plan to pay for the inpatient hospital care. You say that these charges are emergency related 
services and should be covered even though your non-participation status. The Plan denied your request. The 
Plan says the records do not support the medical necessity of the services.  
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 the inpatient hospital care. Our reviewer 
says that the documentation does not support 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. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the initial observation care (99218) provided February 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight (8) home health physical therapy visits (CPT code 
G0151 X 8), for the enrollee. 
 
You asked the Plan to pre-approve home health physical therapy visits. You say that the services are necessary. 
The Plan denied your request. The Plan says the services are not necessary.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapy visits. 
Our physician reviewer found there is no documentation that additional skilled therapy services beyond what 
has been approved by the health plan are required to effectively provide treatment, care, and/or services in 
order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
enrollee's level of function and/or prevent deterioration. Records indicate the enrollee is walking 118 feet with 
contact guard assistance with no assistive device and is contact guard assist for transfers. Records do not 
indicate why the four additional physical therapy visits that were approved (in addition to the previously 
approved visits) are inadequate to treat the enrollee's condition. The four additional visits should be adequate to 
transition the enrollee to a home exercise program and records indicate the enrollee has family available to help 
with their care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve eight (8) home health physical therapy visits (CPT code G0151 X 8), 
for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from October 8, 2020, to 
October 13, 2020. 
 
You asked the Plan to pay for inpatient care. 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 the records do not 
validate diagnosis code A41.9 as the principal diagnosis for this admission. 
 
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 A41.9 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 inpatient care. Our reviewer says that this inpatient stay does 
not meet the criteria for payment at the requested diagnosis related group (DRG) rate. Our physician reviewer 
found sepsis is documented in the record; however, the documentation does not support a rise of 2 or more 
points in SOFA score, treatment addressing sepsis in the medical record is not clearly documented, as well as 
documentation demonstrating life-threatening organ dysfunction to be a dysregulated host response to 
infection.  
 
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 care provided from October 8, 2020, to October 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) coded 93042 provided 
on April 13, 2021. 
 
You asked the Plan to pay for the rhythm electrocardiogram (ECG). You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 
for the rhythm electrocardiogram (ECG) is a column II code to column I code 93010. This claim has not been 
billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for the rhythm electrocardiogram 
(ECG) coded 93042 provided on April 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 22, 
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 due to the enrollee's hospice election at the time of service, this claim must be reviewed 
by Original Medicare first. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided to the enrollee on January 22, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
May 6, 2021. 
 
You asked the Plan to pay for this service. 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 physician services provided to the 
enrollee on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual physical examination provided on June 22, 2021. 
 
You asked the Plan to pay for annual physical exam. You say that you are not sure why the provider billed this 
as a preventive visit. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because you previously received a covered annual physical on April 26, 2021, so this benefit was 
exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months. The Plan has an added benefit for coverage of one annual preventive physical exam per 
calendar year. 
 
At this visit you received an Annual Wellness Visit (AWV), which was covered by the Plan, as well as an 
annual preventive physical. You previously received a covered annual preventive physical exam on April 26, 
2021, so this benefit was exhausted for the 2021 calendar year. Therefore, we decided that the Plan does not 
have to pay for an annual physical examination provided on June 22, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ilumya for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no record from the prescriber about a trial of the preferred drugs. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not 
contain documentation of trial and failure of Humira, Enbrel, or Skyrizi. The documentation does not support 
that Humira, Enbrel, or Skyrizi would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ilumya for the enrollee.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
  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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from November 15, 
2019, through November 18, 2019 billed with secondary diagnosis code R18.8. 
 
You asked the Plan to pay for the inpatient services as billed. You say that it is felt that this claim was billed 
correctly. The Plan denied your request. The Plan says the DRG payment was reduced due to the lack of 
support for diagnosis code R18.8. 
 
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 R18.8, defined as ascites 
not otherwise specified. We asked our coding 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 services as 
billed. Our reviewer says that the documentation does not support the inclusion of code R18.8 as a secondary 
diagnosis for this admission. Our coding reviewer found documentation does not clearly support treatment for 
ascites during hospital stay. As a computed tomography scan was performed before this hospital stay; 
documentation does not clearly document the treatment for this diagnosis. Treatment documented supports care 
for Congestive Heart Failure with exacerbation.  
 
We looked at this coder?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 care provided from November 15, 2019, through November 18, 2019 billed with 
secondary diagnosis code R18.8.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic facet joint block for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the policy requires documentation explaining why a test injection or a temporary 
treatment is needed when a permanent treatment has been completed in the same spine region. 
 
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records document that the enrollee's provider performed radiofrequency ablations to C6-T1 on July 
29, 2021, September 30, 2021, and October 28, 2021. Due to exceeding the number of Medicare allowable 
radiofrequency ablations at this region within 12 months, the provider is asking to perform therapeutic facet 
injections instead. There is no documentation as to why a therapeutic facet joint block would be appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a therapeutic facet joint block for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast (76641) 
rendered on July 13, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound of the breast. You say that you had a 
mammogram and the oncologist office called you and said you needed to go back and have more views and an 
ultrasound for follow up. You also say that this should have been paid as it was part of the diagnostic from the 
first mammogram. 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). Your contract with the Plan clearly says that you must pay a $125 
copayment for Medicare-covered radiological diagnostic services, performed in a physician's office or at a 
free-standing facility.  
 
You have been asked to pay $106.56, which is less than the $125 copayment for an ultrasound of the breast. 
Ultrasounds of the breast 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 an ultrasound of the breast 
(76641) rendered on July 13, 2021.
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 you are appealing with supporting record. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been in the hospital for a week, live alone, 
and need assistance since you are weak. The Plan denied your request. The Plan says the records indicate you 
are not able to ambulate (walk) household distances and you require minimal assistance with transfers which is 
a decline from your prior level of assistance. The Plan states your needs can be met at a lower level of care, 
such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of a humerus fracture after a fall. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 IRF admission and services.