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 SNF care is needed.  The Plan denied your request. 
The Plan says the enrollee does not meet the requirements. Services needed may be provided safely in a lower 
level of care. 
 
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 is a 64-year-old female with a medical history including hypertension, 
and osteoarthritis of the knee who was admitted to the hospital for a planned right total knee arthroplasty. She 
has remained medically stable. The most recent therapy documentation indicates the member is able to 
ambulate with a rolling walker. 
 
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.   
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the WATS cytopathology and histopathology diagnostic testing (88112, 
88361, 88312, 88305) provided October 13, 2022.  
 
You asked the Plan to pay for the WATS cytopathology and histopathology diagnostic testing. You say that 
this testing is recommended in the standard of practice guideline of major medical studies. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of WATS3D testing for screening, 
diagnosis or surveillance of cancerous or pre-cancerous esophageal lesions have not been demonstrated in the 
peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the WATS cytopathology and 
histopathology diagnostic testing. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case.  Our physician reviewer found that the American Society for 
Gastrointestinal Endoscopy has made a conditional recommendation based on low quality evidence and 
suggests using WATS-3D in addition to white light endoscopy in patients with known or suspected Barrett's 
esophagus. The available documentation in the case file supports that the enrollee in this case has known or 
suspected Barrett's esophagus.  
 
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 WATS cytopathology and histopathology diagnostic testing have been met. 
Therefore, we decided that the Plan has to pay for the WATS cytopathology and histopathology diagnostic 
testing (88112, 88361, 88312, 88305) provided October 13, 2022.   
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from May 21, 2023, forward. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs are custodial and 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 the continuation of skilled nursing facility (SNF) care from May 21, 2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on December 24, 2022, by 
an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network service. You say that there are no prior authorization 
requirements for this service.  The Plan denied your request. The Plan says the service is this case was not 
urgent or emergent.  
 
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 at issue in this case is not a network provider with the Plan. 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 out-of-network service. Our physician reviewer found there is no 
documentation of an urgent or emergent condition in this case that could not have been managed by an in-
network provider. Provided records in this case do not document that an in-network provider was unavailable 
to evaluate and treat the enrollee for the enrollee's viral syndrome. Records do not support that the enrollee's 
condition was so urgent or emergent that out-of-network care was reasonable and 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 out-of-network service have not been met.  
 
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 pay for the out-of-network service. Therefore, we decided that the 
Plan does not have to pay for the office visit (99203) provided on December 24, 2022, by an out-of-network 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental pneumatic appliance 
for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you need the 
requested devices because they help with your fluid buildup. The Plan denied your request. The Plan says the 
records do not show you have tried four-weeks of conservative therapy and there has not been any 
improvement. The request is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits and lab services you had on June 4, 2022, 
and August 8, 2022. 
 
You asked the Plan to pay for the office visits and lab services. You did not provide a specific argument with 
your appeal request. The Plan denied your request. The Plan says the provider billed with an incorrect POS 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill with the appropriate Place of 
Service (POS) code to indicate where the services took place.  POS code 12 indicates that the services occurred 
in the home. Services occurring in an office setting should be billed with POS code 11. 
 
In this case, the provider billed the services in dispute with POS code 12, indicating that the services occurred 
in the home.  However, the records clearly show that the services occurred in an office setting.  As a result, the 
provider should have billed POS code 11.  The Plan cannot be required to pay for these services because they 
were not billed correctly. You have the right to contact the provider directly to request that they correct their 
claims. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visits and lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visits and lab services you had on June 4, 2022, and August 8, 2022.
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 continued admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says there is no longer a need for daily skilled care.  
 
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 enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs are custodial and 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: 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 would like to get home from being temporarily 
relocated to be near your family and support system. The Plan denied your request. The Plan says your records 
do not show that your current facility is not meeting these requirements. You are receiving daily skilled 
services. 
 
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 is an 82-year-old male with a medical history including hypertension, 
hereditary neuropathy, a seizure disorder and a need for an indwelling catheter who was hospitalized due to a 
periprosthetic femur fracture. He was treated and discharged to a skilled nursing facility on May 20, 2023, for 
inpatient therapies. The most recent therapy documentation indicates the member is dependent for functional 
mobility tasks and requires assistance for self-care tasks. The member is medically stable and does not have 
any complex daily wound care, parenteral medications or required care for a new or malfunctioning feeding 
tube. 
 
The member has remained medically stable. The member does appear to continue to require skilled therapyor 
nursing services on a daily basis.   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on December 20, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 requested 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 an office visit (99214) provided on December 20, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 5, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records.  The Plan 
denied your request. The Plan says this was not authorized. 
 
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 requested 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 nursing facility care provided on January 5, 2023, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on December 8, 2022, billed with 
code G0452-59. 
 You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this service is bundled into payment 
for another code. 
 
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 G0452-59 is a column II code to column I codes 81206, 81207, 
81208, and 81170; however, G0452-59 was billed with a modifier.  
 
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 the testing services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found G0452 is used to report a medically 
necessary interpretation and written report of a molecular pathology test, above and beyond the report of 
laboratory results.  Laboratory report submitted, does not meet criteria for service billed.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on December 8, 2022, billed with code G0452-59.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
14-day sensor (A4239). You asked the Plan to pre-approve a Freestyle Libre 2 CGM 14-day sensor. You say that the device should be 
covered because the enrollee has been using the Freestyle Libre for almost 5 years. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for approval of the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 2 CGM 14-day sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 14-day sensor (A4239).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99358, 99309) provided from July 7, 
2022, to July 14, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for physician services. You say that the enrollee could not choose a different doctor. 
The Plan denied your request. The Plan says this was not authorized. 
 
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 requested 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 physician services (99358, 99309) provided from 
July 7, 2022, to July 14, 2022, by an out-of-network (OON) provider.