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

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on April 
27, 2022, to May 22, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $0 per 
day, days 1-20; $178 per day, days 21-100 for each Medicare-covered SNF stay. Days covered: You are 
covered for up to 100 days per benefit period. A prior hospital stay is not required. We will only cover your 
stay if you meet certain Medicare guidelines, and your stay is medically necessary. There was a total of 26 
days. For days 21-26 there is a $178 copayment. $178 x 6 = $1,068. Therefore, results in the total cost sharing 
amount of $1,068.  
 
 You have been asked to pay a $178 copayment per day for skilled nursing facility (SNF) care. This 
item/service falls within the Skilled nursing facility (SNF) care 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 skilled nursing facility (SNF) care on April 27, 2022, to May 22, 2022.
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 would benefit from IRF services. The 
Plan denied your request. The Plan says IRF care 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 the enrollee does not require intensive therapy to recover from the hip and arm 
fracture. He does not have complex or specialized rehabilitation needs. His fractures have been repaired. He needs to regain strength and balance which are routine therapy needs which do not require an IRF admission. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 17, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 17, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 75710 and 75630 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for codes 75710 and 75630. You say that these services are supported as billed and 
should be paid separately. The Plan denied your request. The Plan says the payment for codes 75710 and 75630 
is included in the payment for code 37225. The medical records provided do not support separate payment for 
these services.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 codes 75710 and 75630. Our reviewer says that codes 75710 
and 75630 are not separately payable in this case. For code 75710, the operative report documents "Using a 
Seldinger technique, we then positioned a 6 French sheath in the right femoral artery under ultrasound 
guidance.  A selective right SFA angiogram was then performed, followed by a right selective infrapopliteal 
runoff under DSA".  The operative report describes an angiography extremity with revascularization.  In this 
case, medical record does not support a previous angiography was not performed, or condition has 
changed.  Revascularization procedures include operative angiograms/venograms and therefore this procedure 
cannot be verified, as a separate procedure. For code 75630, the operative report documents "Over a 0.035 
wire, we positioned a 5 French RBI catheter in the abdominal aorta and brought the level of the distal 
aorta.  We performed a distal abdominal aortogram with bilateral iliofemoral runoff under DSA...Orbital 
Atherectomy was then performed of the left mid superficial femoral, distal superficial femoral and popliteal 
arteries using a CSI Stealth 360 arthrectomy catheter".  In this case, a revascularization procedure was 
performed, which includes operative angiograms and/or venograms. Our reviewer found  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 75710 and 75630 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 75710 and 75630 billed for date of service June 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital admission. 
 
You asked the Plan to pre-approve acute inpatient hospital admission. You say that the inpatient stay is 
medically necessary. The Plan denied your request. The Plan says the procedure is not on the CMS inpatient 
only list. The preoperative clearance and comorbid conditions suggest that the procedure could initially be 
performed on an ambulatory/observation basis. There is no need to prospectively approve the inpatient 
admission. The denial of the requested elective inpatient admission was appropriate given the clinical scenario 
and the guidance presented above. 
 
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 pre-approve acute inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for acute inpatient hospital admission is 
met. Our physician reviewer found the enrollee is undergoing a planned left total shoulder arthroplasty. He is 
medically stable and has been provided medical clearance to undergo this elective procedure. The planned 
procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is 
currently approved as an ambulatory procedure. There is no documentation provided to support the expectation 
the enrollee will require a greater than 2 midnight stay. The review indicates that the record did not show that at 
the time of inpatient admission the admitting physician reasonably expected that the enrollee'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 admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve acute inpatient hospital admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on March 21, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
services provided on March 21, 2022.
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 was admitted for metabolic encephalopathy, sepsis, and COVID 
infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient clinic visits and specialist 
services provided from February 12, 2021, to January 18, 2022. 
 
You asked the Plan to waive the copayment for outpatient clinic visits and specialist services. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
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 $15 
copayment for outpatient department visits and a $25 copayment for treatment by a specialist.  
 
You have been asked to pay a $15 copayment and a $25 copayment for outpatient clinic visits and specialist 
services. These services fall within the physician/practitioner services, hospital outpatient department and 
treatment by a specialist 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 outpatient 
clinic visits and specialist services provided from February 12, 2021, to January 18, 2022.
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 SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested continuation of SNF care is not medically reasonable and necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that as of the last covered day, you did not require any skilled nursing or skilled 
rehab services on a daily basis. You were not expected to make measurable gains within a reasonable and 
predictable period of time of require skilled therapy to prevent deterioration with mobility or self-care tasks. 
You did not require skilled therapy to establish a safe and effective maintenance program. As a practical 
matter, you did not require any skilled services on an inpatient basis, at a skilled level of care as of 11/30/22. In 
terms of skilled nursing, you require only custodial care. You can be discharged to a lower level of care for 
further 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day CGM sensor. You say that you feel like this should 
be covered. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for the 
requested CGM sensor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14-day CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre 14-day continuous glucose monitor (CGM) sensor.
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 was admitted for altered mental status and respiratory failure. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this 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: 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 have provided records to support this request. 
The Plan denied your request. The Plan says SNF care is not medically necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the member has stabilized medically and is ready for discharge from the 
hospital.  The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is 
medically stable and can receive further rehab services at a lower level of care. Although further rehab services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing facility. The member does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any 
acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can 
receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehab services is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intrathecal pump programming, medication, home 
visits, and associated supplies to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an intrathecal pump programming, medication, home visits, and associated 
supplies. You say that you have contacted 4 in-network providers and they are not capable to do compound for 
an Intrathecal Pain Pump. The Plan denied your request. The Plan says services requested are available from 
in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an intrathecal pump programming, medication, home visits, and associated supplies to be provided by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
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 requested service is not covered by Medicare or the health plan. 
 
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 that you had a negative stress test but did not achieve the intended heart rate, you stopped because of 
dyspnea. His symptoms were duplicated, with no evidence of ischemia on electrocardiogram. The guidelines 
do not support a need for cardiac catheterization in this setting. If the physician remains concerned with 
possible cardiac ischemia, other non-invasive imaging could be performed, such as coronary computed 
tomography (CT) scan or radionuclide stress test. As a result, at this time cardiac catheterization would not be 
considered medically appropriate and necessary in your clinical management. 
 
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 cardiac catheterization.