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 enrollee would benefit from a longer course of 
therapy at a less intensive rate. The Plan denied your request. The Plan says the denial of SNF care is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 27, 2022, to 
September 25, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the NOA several times. 
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 August 27, 2022. The NOA was not received by the Plan until March 29, 
2023. 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 August 27, 2022, to September 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on December 30, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on December 30, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services performed on May 16, 2023, through 
May 21, 2023. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the inpatient hospital services should 
be paid as billed because they were reported accurately. The Plan denied your request. The Plan says that the 
number of inpatient days billed does not correspond with the date span on the claim.  
 
The Plan must follow Medicare rules. Medicare rules say outpatient services provided by the admitting hospital 
within the 3 days prior to and including the date of a formal admission are considered inpatient services and are 
included in the inpatient claim. 
 
We looked at the file and Medicare rules. Although it is documented that the enrollee was seen in the 
emergency department on May 16, 2023, and received an endoscopy procedure earlier on May 17, 2023, 
records show the enrollee was not formally admitted as an inpatient until the evening of May 17, 2023. They 
were discharged on May 21, 2023. As such, billing 4 units of room and board for 4 inpatient bed days is 
accurate. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital 
services have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital services 
performed on May 16, 2023, through May 21, 2023.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied claim for LTACH services and that the services requested are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
LTACH services. 
 
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 the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0427-HH, A0425-HH) provided 
on November 29, 2022. 
 
You asked the Plan to pay for ambulance transportation. You say that these services were emergent and should 
be paid separately. The Plan denied your request. The Plan says the payment for this service is included in the 
facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered 
patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance transportation have not been met. Specifically, the record shows that the enrollee 
maintained inpatient status at one facility throughout the date in question. This means that the services at issue 
are considered patient transportation and paid to the facility. Therefore, we decided that the Plan does not have 
to pay for ambulance transportation (A0427-HH, A0425-HH) provided on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 82607 and 84207 provided 
on April 12, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that the lab must see all patients that need care. 
The provider has no option to determine which patient to perform services on. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 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 the laboratory services coded as 82607 and 84207 
provided on April 12, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87641, 87653, 87500, 87640, 87481, and 
87798 billed for October 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87641, 87653, 87500, 87640, 87481, and 87798 are not supported. 
 
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, the CPT Code Manual definition of code 87641 is infectious agent detection by nucleic acid (DNA 
or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 
87653 is infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe 
technique. The definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); 
vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified 
probe technique. The definition of code 87481 is infectious agent detection by nucleic acid (DNA or RNA); 
Candida species, amplified probe technique. The definition of code 87798 is infectious agent detection by 
nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT codes 87641, 87653, 87500, 87640, 87481, and 87798 are not supported in the medical 
record. Specifically, the records show a panel was performed and there is a more appropriate single code for 
the services. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87641, 87653, 87500, 
87640, 87481, and 87798 billed for October 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bupivacaine (J3490). 
 
You asked the Plan to pre-approve Bupivacaine. You say that Bupivacaine is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Bupivacaine. Our reviewer says that 
this drug is not medically necessary. Our physician reviewer found further studies are needed to determine the 
safety and effectiveness of intrathecal bupivacaine. Bupivacaine compounded for an intrathecal pump is not 
FDA approved for the enrollee's diagnosis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bupivacaine have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Bupivacaine (J3490).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on April 27, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. The Plan denied your request. 
The Plan says this is not a covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on May 24, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that the enrollee's 
treating physician determined this testing to be medically necessary to successfully treat the enrollee. The Plan 
denied your request. The Plan says this testing was medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is covered when the criteria in 
the rules section of this letter are met. 
 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 definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
provider record notes no specific concern for drug abuse/misuse. There is no evidence that the urinary drug 
screen results were reviewed prior to ordering the UDT. The UDT was not tailored to the enrollees addictions 
and/or medications. Therefore, the documentation does not support that the provided, broad-sweeping, 
confirmatory UDT was medically necessary or reasonable. 
 
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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on May 24, 2023.
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 is medically stable and needs physical 
therapy. The Plan denied your request. The Plan says an IRF admission 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 need intensive therapies consisting of at least 3 hours of therapy 
per day at least 5 days per week with multidisciplinary approach in an IRF. The documentation does not 
support necessity for admission to an IRF. The complexity of the enrollees medical, rehabilitation, and nursing 
needs (combined complexity does not require acute hospital inpatient rehabilitation stay with an 
interdisciplinary approach to rehabilitative care. The enrollees rehabilitation needs can be safely provided in 
an alternate and low intensity setting such as in an SNF.  
 
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 TissueCypher Barretts Esophagus test (0108U) provided 
January 17, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that your claim for the TissueCypher Barrett's 
Esophagus test was denied in error and you are requesting it be reprocessed and paid. The Plan denied your 
request. The Plan says TissueCypher Barretts Esophagus test remains unproven for determining the risk of 
progression from Barretts esophagus to high grade dysplasia or cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the TissueCypher Barretts Esophagus test (0108U) provided January 17, 2023.
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 enrollee resides alone, and their children can 
provide limited assistance for care. The enrollee was independent prior to their condition and is requesting that 
they continue to receive therapy until they are able to return home. The Plan denied your request. The Plan says 
the skilled nursing facility (SNF) services requested do not meet the requirements for approval. 
 
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 daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve cardiac catheterization. You say that you have an aneurysm that needs to be 
taken care of. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 
you can be treated within the Plan network. 
 
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 
cardiac catheterization to be provided by an out-of-network (OON) provider.
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 like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission 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 need intensive therapies consisting of at least 3 hours of therapy 
per day at least 5 days per week with multidisciplinary approach in an IRF. The documentation does not 
support necessity for admission to an IRF. The complexity of the enrollee's medical, rehabilitation, and nursing 
needs (combined complexity does not require acute hospital inpatient rehabilitation stay with an 
interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs can be safely provided in an 
alternate and low intensity setting such as in a skilled nursing facility (SNF).  
 
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.