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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. You are ambulating household distances and tending to ADLs with 
minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be 
provided at a lower level of 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 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 sensory integrative techniques to enhance sensory processing 
and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 
minutes (97533) to be provided by an audiologist. 
 
You asked the Plan to pay for sensory integration. You say that this service would help with your dizziness. 
The Plan denied your request. The Plan says this service is not covered when provided by an audiologist. 
 
The Plan must follow Medicare rules. Medicare rules say that sensory integration may be covered when 
provided by a speech pathologist. 
 
We looked at the file and Medicare rules. In this case the sensory integration is requested to be performed by an 
audiologist. Based on this information, we decided that Medicare rules for coverage of sensory integration have 
not been met. Therefore, we decided that the Plan does not have to pay for sensory integrative techniques to 
enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) 
patient contact, each 15 minutes (97533) to be provided by an audiologist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 5, 2022. 
 
You asked the Plan to pay for the laboratory 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 separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 provided on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left shoulder surgical arthroscopy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show at least six weeks of non-operative therapy. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no recent trial of physical therapy for shoulder pain. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left shoulder surgical arthroscopy for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computerized tomography (CT) scan. 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee is high risk for cancer due to 
immunosuppressive therapy. The Plan denied your request. The Plan says that the lesion on the enrollee's lung 
is not a lung nodule and per the national coverage determination guidelines lung nodules which increase in size 
or number should no longer be considered for CT screening. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
service is reasonable and medically necessary. Our physician reviewer found that this enrollee has an 
fluorodeoxyglucose avid upper lung mass that is being followed for suspicion of malignancy. Although the 
mass is smaller the risk remains of an underlying malignancy as still remains greater than 3cm and risk of a 
postobstructive pneumonia from underlying malignancy remains, especially given long-term 
immunosuppression. Continued surveillance until stability would be recommended and an increment of 3 
months is standard when following for malignancy (suspected in her 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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computerized tomography (CT) scan.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on 
August 13, 2021. 
 
You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, this code has a professional 
component/technical component indicator of 1. The appropriate place of service code for the interpretation (or 
PC) is the setting where the beneficiary received the technical component service. In addition, the 
documentation shows that another provider rendered the same code on the same date of service at place of 
service 22 (outpatient hospital). Based on this information, we decided that Medicare rules for coverage of the surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical pathology services coded 88305 provided on August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479-59) provided on September 15, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this is supported by the records. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that it was appropriate to bill the -59 modifier. Specifically, the 
code billed with the modifier was not billed with other services. Based on this information, we decided that 
Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided 
that the Plan does not have to pay for genetic testing (81479-59) provided on September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 25, 2022, to February 28, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the criteria were not met for the inpatient level of care. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the review has determined that the record did not show 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. The procedure was not listed on the 
2022 Inpatient Only Procedure List. There was a delay in care since the enrollee was fully stable and could 
have received the procedure on the first day, but did not receive it until the third day. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from February 25, 2022, to 
February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service January 17, 
2022. 
 
You asked the Plan to pay for procedure code 99255. You say that you have provided records to support the 
services at issue. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 find that CPT code 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99255 billed for date of service January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided on January 4, 
2022. 
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you didn't have the treatment 
so you shouldn't be charged. The Plan denied your request. The Plan says the coinsurance 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). Your contract with the Plan clearly says that you must pay 20% of 
the total cost for each Medicare-covered outpatient surgery at a hospital outpatient facility.  
 
 
 
 
 
 You have been asked to pay $177.37 which is 20% of the allowed amount for outpatient surgery.  The allowed 
amount is $886.83 (20% x $886.83= $177.37). Outpatient surgery 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 coinsurance for outpatient surgery provided on January 4, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), 
amplified probe technique (87635) provided for travel on December 17, 2021. 
 You asked the Plan to pay for the COVID-19 testing. You say that the test was required to enter Chili in 
December and the only option for the test was for testing at the airport. The Plan denied your request. The Plan 
says this service is not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the COVID-19 testing, was requested solely for travel purposes. Medicare does 
not cover this test solely for traveling purposes. Therefore, we decided that the Plan does not have to pay for 
the infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 
(SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique (87635) provided for travel on 
December 17, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from September 28, 2021, through 
October 26, 2021, billed with code 1HC11 or 2HC11. 
 
You asked the Plan to pay for the home health services as billed. You say that it is felt that this was coded 
correctly on the OASIS form, and that the HIPPS code billed is correct. The Plan denied your request. The Plan 
says that the M1850 score should be 1 (Able to transfer with minimal human assistance or with use of an 
assistive device.) 
 
The Plan follows Medicare rules. Medicare rules say that coding of HHRGs for home health episodes of care 
are calculated by the OASIS form. The OASIS-D Guidance provides more information for coding each field on 
the form. 
 
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 home health services as billed. Our 
reviewer says that the functional score reported by the HH agency is supported by the medical records 
provided. Our physician reviewer found the enrollee was a then 90-year-old man who was admitted to HH 
following a nursing facility stay. The enrollee has a medical history of diabetes, atrial fibrillation, and 
hypertension. The enrollee was reported to have generalized weakness with unsteady ambulation. On 
September 28, 2021, it is documented that the enrollee had difficulty transferring, and needed human assistance 
or device. The enrollee was able to bear weight and pivot during the transfer process but was unable to transfer 
self. It is documented on multiple occasions that the enrollee had difficulty transferring and that human 
assistance or device were needed. The reported functional score of 2 is supported in this case as the enrollee is 
"Able to bear weight and pivot during the transfer process but unable to transfer self". 
 
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 home health services as billed have been met. Therefore, we decided that the 
Plan has to pay for the home health services provided from September 28, 2021, through October 26, 2021, 
billed with code 1HC11 or 2HC11.   
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for group psychotherapy provided from June 1, 
2021, to December 30, 2021. 
 
You asked the Plan to waive the copayment for group psychotherapy. You say that you dont believe the 
enrollee should have any responsibility. 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). Your contract with the Plan clearly says that you must pay $45 
copayment for each covered partial hospitalization visit.  
 
You have been asked to pay a total of $2,312.24 copayment for each group psychotherapy visit. Group 
psychotherapy visits fall within the Partial Hospitalization Services 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 group psychotherapy provided from June 1, 2021, to December 30, 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for 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 
services are not medically necessary. Our physician reviewer found there are no services offered at a SNF that 
are not offered at an inpatient rehabilitation facility. Admission to a SNF for inpatient skilled rehabilitation 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood administration, collection of venous blood by 
venipuncture, concentration for infectious agents, electrosurgical probe, syringes and walker billed with the 
inpatient services provided on April 25, 2021, through May 15, 2021. 
 
You asked the Plan to pay for the blood administration, collection of venous blood by venipuncture, 
concentration for infectious agents, electrosurgical probe, syringes and walker. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says these are routine 
items and services. 
 The Plan must follow Medicare rules. Medicare rules say that routine services are the regular room, dietary and 
nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and 
the use of certain equipment and facilities for which a separate charge is not customarily made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the blood administration, collection of venous blood by venipuncture, concentration for infectious 
agents, electrosurgical probe, syringes and walker have not been met. Specifically, the items and services at 
issue are considered routine and payment is bundled into the Room and Board charge. Therefore, we decided 
that the Plan does not have to pay for the blood administration, collection of venous blood by venipuncture, 
concentration for infectious agents, electrosurgical probe, syringes and walker billed with the inpatient services 
provided on April 25, 2021, through May 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Continuous positive airway pressure (CPAP) therapy. 
 
You asked the Plan to pre-approve Continuous positive airway pressure (CPAP) therapy. You say that the 
requested CPAP is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested CPAP. 
 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 Continuous positive airway pressure 
(CPAP) therapy. Our reviewer says that the enrollee does not meet criteria for the requested CPAP. Our 
physician reviewer found continued CPAP is not medically necessary because the enrollee has been unable to 
use the device enough to be beneficial or to meet minimum Medicare use criteria of at least 4 hours/day for at 
least 70% of days. The most recent compliance download showed 38.9% of days with at least 4 hours/day. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Continuous positive airway pressure (CPAP) therapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Continuous positive airway pressure (CPAP) 
therapy.