Persius/hicric huggingface dataset:
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 the enrollee can benefit from 15 hours of therapy a 
week and requires daily physician oversight to actively manage medical conditions and comorbidities to 
optimize their recovery. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's needs can be met at an alternate level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 the enrollee would benefit from inpatient 
rehabilitation and more oversight before going home. You say that the enrollee lives alone and are unable to 
care for themselves.  The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
and the enrollee's needs can be met in other settings.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
February 07, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit for the 
evaluation and management provided on February 07, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the abdomen and pelvis, and sedation 
services. 
 
You asked the Plan to pre-approve an MRI of the abdomen and pelvis, and sedation services.. You say that the 
requested MRI is medically necessary due to your health issues and symptoms. The Plan denied your request. 
The Plan says an MRI of the abdomen and pelvis is not medically necessary. The Plan also says sedation 
services are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the abdomen and pelvis, and 
sedation services. Our reviewer says that the requested MRI of the abdomen and pelvis and sedation services 
are not medically necessary. Our physician reviewer found you have a history of Agent Orange exposure which places you at risk for malignancy of various types. You had a recent colonoscopy however the report is not in 
the records. You had a computed tomography (CT) urogram in January 2023. There has been no recent 
ultrasound of the abdomen and no scrotal ultrasound. The medical necessity for the requested MRI of the 
abdomen and pelvis has not been established for this patient for whom MRI of the lumbar spine has already 
been approved. 
  
As the primary procedures are not covered, sedation is also not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the abdomen and pelvis, and sedation services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an MRI of the abdomen and pelvis, and 
sedation services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (81226, 81291) provided 
January 6, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you are appealing the denial that the GeneSight 
Psychotropic test is not medically necessary. The Plan denied your request. The Plan says the information 
received did not meet medical necessity criteria. 
 
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 pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has a diagnoses of anxiety disorder, unspecified (F41.9) and depression, 
unspecified (F32.A). The enrollee has no history of adverse effects related to psychotropic medications and 
initially had a positive response to the drugs that they were taking at the time this gene testing was performed. 
It does not appear that the enrollee has been evaluated for the cause of their hot flashes, which at age 68 are 
very unlikely to be related to menopause. There is no indication that the Family Medicine Nurse Practitioner 
had considered non-genetic factors in making a drug selection for this enrollee at any time. The review has 
determined that the items/services at issue in this case are not medically reasonable or 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the GeneSight Psychotropic test (81226, 81291) provided January 6, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110, 97530, 97116) provided on 
December 14, 2022. 
 
You asked the Plan to pay for the therapy services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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 97110, 97530, & 97116 is not supported in the medical record. Specifically, diagnosis 
codes R26.9  (Unspecified abnormalities of gait and mobility) and R27.0 (Ataxia, unspecified) have an exclude 
not and cannot be billed together. Based on this information, we decided that Medicare rules for coverage of 
the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy 
services (97110, 97530, 97116) provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 18, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
January 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 18, 2023, billed with 
procedure code 73140. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says code 73140 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
STV-packaged services are assigned status indicator Q1. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the imaging services provided have not been met. Code 73140 has a status indicator of Q1and code 
99283 has a status indicator of V, as such code 73140 is not payable. Therefore, we decided that the Plan does 
not have to pay for imaging services provided on February 18, 2023, billed with procedure code 73140.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post-stabilization services provided from March 16, 
2022, to March 23, 2022.   
You asked the Plan to pay for the post-stabilization services. You say that the managing physician(s) are of the 
opinion that the services provided were medically appropriate and necessary at the level of care provided. You 
also say that any lesser level of care could have put the enrollee at elevated risk for sudden clinical 
deterioration and adverse events.  The Plan denied your request. The Plan says  the non-contracted facility 
refused to coordinate transfer and informed the Plan that they would move forward with admitting the enrollee 
without approval from the Plan.  
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization services. Our physician 
reviewer found the provided documentation did not clearly show the treating physician reporting the enrollee as 
not stable for transfer on any date of service. It was noted the enrollee was stable and appropriate for transfer 
on March 16, 2022, at 16:54. 
 
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 post-stabilization services have not been met. Therefore, we decided that the 
Plan does not have to pay for the post-stabilization services provided from March 16, 2022, to March 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 10, 
2022, to February 20, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this stay was medically necessary. The 
Plan denied your request. The Plan says the whole inpatient stay was not medically necessary. 
 
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 determined that the record did not show that the full length of the inpatient stay 
provided was 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided December 10, 2022, to February 20, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically 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 services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not show any recent medication changes or clinical concerns thus the records do not show 
that skilled nursing services in home setting would be required. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telemedicine visit provided on February 14, 2023. 
 
You asked the Plan to pay for a telemedicine visit. You say that the enrollee was in a nursing home at the time 
that the services were rendered. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a telemedicine visit 
provided on February 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 22, 2022, to August 
17, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 22, 2022. The NOA was not received by the Plan until August 31, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from July 22, 2022, to August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee's condition would benefit from a 
ventilator. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this 
purpose, but the Plan has approved continued use of the ventilator for 3 months while the appropriate 
equipment is arranged for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee's needs can be met in the current hospital 
setting.  
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ultrasound provided on February 13, 
2023. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that the Plan should pay more for this 
service. 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 $110 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $110 copayment for the ultrasound. This item/service falls 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 reduce the 
copayment for the ultrasound provided on February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the advanced microprocessor knee (MPK) with a 
vacuum-assisted socket system (VASS).  
 
You asked the Plan to pre-approve the MPK with VASS. You say that the requested items should be approved.  
The Plan denied your request. The Plan says the items are not necessary.  
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee.  
 
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 MPK with VASS. Our reviewer 
says that the requested items are not medically necessary.  Our physician reviewer found a level 3 ambulator 
has the ability or potential for ambulation with variable cadence.  Typical of the community ambulator who has 
the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity 
that demands prosthetic utilization beyond simple locomotion. This is required for the MPK, but the 
documentation does not support it.  In addition, the VASS has not been shown to be superior to other standard 
treatments for the medical condition.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MPK with VASS have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the advanced microprocessor knee (MPK) with a vacuum-assisted socket system 
(VASS).