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

 
We decided that the Plan does not have to waive the copayment for an in-network injection procedure provided 
on July 17, 2023. 
 
You asked the Plan to waive the copayment for an in-network injection procedure. You say that you had to go 
to a new building and got charged more. You want this cost waived as you did not have a choice. 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 $275 
copayment for outpatient hospital services. 
 
You have been asked to pay a $275 copayment for an in-network injection procedure. This item/service falls 
within the outpatient hospital 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 
an in-network injection procedure provided on July 17, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice services rendered from December 1, 2022, to 
December 29, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the hospice claims must be billed with a metropolitan 
statistical area (MSA) or Core-Based Statistical Area (CBSA) number (or rural State code) of the location 
where the hospice service is delivered. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required CBSA 
code. 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 the hospice services rendered from December 
1, 2022, to December 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee was admitted from a skilled nursing 
facility. He has failed the lower level of care and is needing a higher level of care to meet his complex needs. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) for an 
approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller. You say that this feature is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when 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 expandable controller. Our reviewer 
says that the expandable controller is not medically necessary. Our physician reviewer found the enrollee has 
sufficient ability to operate the power functions using the standard switches. 
 
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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) for an approved power 
wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 17, 2023, to 
April 20, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
codes and diagnoses reported on this claim are appropriate and supported as billed. The Plan denied your 
request. The Plan says one of the diagnoses reported on this claim is not supported in the records provided; 
therefore, the submitted DRG is changed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 - sepsis, unspecified organism. 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 inpatient hospital services at the DRG originally billed. 
Our physician reviewer found the workup revealed normal platelet count, bilirubin, blood pressure, mental 
status, urination, but had creatinine of 1/53 on presentation, not repeated after fluids, however. The Sepsis 3 
criteria were not met for this admission as the Sequential Organ Failure Assessment (SOFA) score was not 2+, 
and there was not significant evidence for organ failure directly related to a dysregulated response to systemic 
infection as required. Therefore, the code, sepsis, unspecified organism (A41.9), is not sufficiently supported 
for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 17, 2023, to April 20, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from July 26, 2022, to 
November 16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a line by line review of both the itemized bill and the medical records was performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report contains no 
documentation of ANESTH ADMIN LOCAL for July 31, 2022. The records include a procedure report for the 
bladder scans but does not include the physician order. The scans cannot be verified. A physician order or 
documentation in the procedure report was not found for CATH INF PER/CENT/MIDLINE, CHEST WALL 
MANIPULATION, INSERT NON-INDWELLING BLADDER CAT, NEG PRES WOUND THER DRSG 
SET, NEG PRESS WOUND TX >50 CM, NT SUCTION, OFFICE/OP VISIT EST LVL3, PROC 
PERFORMED OUTSIDE OR, or US GUIDE VASCULAR ACCESS. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services rendered from July 26, 2022, to November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmological services provided on 
August 07, 2023. 
 
You asked the Plan to waive the copayment for the ophthalmological services. You say that this service should 
be fully covered. 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 $30 
copayment for vision care. 
 
You have been asked to pay a $30 copayment for the ophthalmological services. This item/service falls within 
the vision care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ophthalmological 
services provided on August 07, 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 you struggle with planning and cooking meals, 
scheduling appointments, and staying organized in your daily life. You say that Huntington's Disease is like a 
combination of Amyotrophic lateral sclerosis (ALS) and Alzheimer's, all in one. The Plan denied your request. 
The Plan says admission to an IRF 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for cervical spine surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee is medically stable with no acuity and does not need physician 
supervision 3 times a week in an IRF. No acute rehab skilled nursing needs are identified or documented. The 
enrollee needs routine physical occupational and therapy (PT/OT) and does not need specialized 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. With no medical 
complexity, and no rehab nursing needs as described above the enrollee does not require an IRF stay. The 
enrollees rehab needs can be provided in an alternate and low intensity setting such as in a skilled nursing 
facility or continued services at home.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face down recovery system (E1399, A9901) purchased 
February 27, 2023. 
 
You asked the Plan to pay for the face down recovery system. You say that this chair was essential in the 
healing and recovery of your vision from when you suffered a detached retina. The Plan denied your request. 
The Plan says this item does not meet the definition of DME and does not serve a purpose that is primarily 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the face down recovery system (E1399, A9901) purchased 
February 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0691) provided 
July 25, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that you have attached all of the 
supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says the medical 
necessity coverage criteria was not met for a UV phototherapy wand in the setting of lumbar radiculopathy.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The record does not show a diagnosis of psoriasis. There is also no 
indication that intractable psoriasis, as there is no indication the enrollee has failed other treatments for 
psoriasis. There are also no other factors described that would justify treatment at home rather than alternative 
sites, like a clinic or the hospital. Based on this information, we decided that Medicare rules for coverage of the 
ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pay for 
the ultraviolet (UV) light therapy system (E0691) provided July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 20, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee is in a nursing home. 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 the laboratory services 
provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation provided on August 16, 
2023. 
 
You asked the Plan to pay for the interrogation device evaluation. You say that you say that the service was 
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 the interrogation device 
evaluation provided on August 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. You asked the Plan to pre-approve SNF care. 
You say that admission to a SNF is medically necessary. The Plan denied your request. The Plan says your 
records do not show that you require skilled services on a daily basis.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services provided on June 
29, 2023. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that that you were never 
charged a $30 copay whenever you went to urgent care, only $15. 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 $30 
copayment for urgently needed services. 
 
You have been asked to pay a $30 copayment for the urgent care services. This item/service falls within the 
urgently needed 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 the urgent 
care services provided on June 29, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on June 1, 2023, billed with code 87077. 
 
You asked the Plan to pay for the lab services as billed. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says that the records are not sufficient to support payment for this 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, the CPT Code Manual definition of code 87077 is culture, bacterial; aerobic isolate, additional 
methods required for definitive identification, each isolate. 
 
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 lab services as billed. Our reviewer says that the 
documentation supports the billed code. Our reviewer found the documentation includes evidence that a urine 
culture was performed.  
 
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 lab services as billed have been met. Therefore, we decided that the Plan has 
to pay for the lab services provided on June 1, 2023, billed with code 87077.  
 
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.