Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from March 4, 2023, to 
March 8, 2023. 
 
You asked the Plan to pay for the inpatient hospital care. You say that this was an inappropriate denial for level 
of care. You say that the enrollee was not stable for transfer. You also say that a post-stabilization notice was 
faxed to the enrollee's plan in a timely manner. The Plan denied your request. The Plan says this was paid at the 
emergency room (ER) level of care. 
 
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 inpatient hospital care. Our reviewer 
says that the inpatient hospital care was not medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollee was stable for transport to an in-plan facility at the time of admission, 
following the emergency department evaluation. The reviewer found that any care provided after this time is 
post-stabilization care and therefore not covered unless pre-authorized. Therefore, the reviewer found that the 
inpatient hospital care was 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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided from March 4, 2023, to March 8, 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 home health services and that the services requested are medically necessary. 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 provided 
records in this case do not clearly document that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
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. You say that admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an LTACH care. 
 
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 is receiving appropriate care at the present acute care hospital. 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. 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: 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 cannot be safely discharged home. They 
require IRF services. The Plan denied your request. The Plan says the request 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the scan is needed to clarify the diagnosis 
between FTD, AD and dementia to help guide future treatment. The Plan denied your request. The Plan says 
the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the record indicates the enrollee most 
likely has AD. The record provided does not establish that the enrollee meets the diagnostic criteria of both AD 
and FTD. The elements of the coverage criteria are not satisfied. The requested service cannot be covered at 
this time. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 29, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not be billed 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 $265 
copayment for ambulance services.  
 
You have been asked to pay a $265 copayment for ambulance services. This item/service falls within the ambulance 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 ambulance services 
provided on April 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided 
from April 21, 2023, to May 16, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is not a covered benefit. The Plan must follow 
Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) is not covered by 
Medicare. Therefore, we decided that the Plan does not have to pay for a fluid circulating cold pad with pump 
(E0218) provided from April 21, 2023, to May 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain.  
 
You asked the Plan to pre-approve the PET scan. You say that the requested imaging is medically necessary to 
clarify the diagnosis between FTD, AD, and dementia and to guide future treatment. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that, based on the medical records, the 
enrollee has been diagnosed with what is most likely AD with a differential diagnosis of issues post-stroke. The 
records did not otherwise support or indicate that diagnostic criteria for FTD had also been met as required by 
the policy. In as much, the criteria for coverage of this service have not been met at this time.  
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for morphometric analysis, tumor immunohistochemistry (88361) provided 
May 10, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
claim that has been denied for multiple reasons. Wats3D is billed utilizing the four CPT codes listed: 88112, 
88305, 88312 and 88361. The Plan denied your request. The Plan says that the supporting documentation does 
not match the information sent on the claim. 
 
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 88361 is morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu, estrogen 
receptor/progesterone receptor), quantitative or semiquantitative, each antibody. 
 
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 laboratory service. Our reviewer says that the 
documentation submitted support that the criteria has been met for the billed services. Our reviewer found the 
laboratory report include documentation of Morphometric analysis, tumor immunochemistry. The lab analyst 
applies a single antibody stain on a slide or slides prepared from a single patient specimen, such as tumor 
tissue. The lab analyst processes the slides using computer assisted technology that counts or estimates the 
number of stained cells. This procedure was documented in laboratory report. 
 
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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for morphometric analysis, tumor immunohistochemistry (88361) provided May 10, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 19, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the diagnoses billed were correct. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R44.3 has an Excludes1 note in relation to F28. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance services provided on April 19, 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 the enrollee needs SNF care for their ulcers and 
rehabilitation for their weakness. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 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 have 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 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: Favorable

 
We decided that the Plan has to pay for code 77427, defined as radiation treatment management, five 
treatments, billed on May 8, 2023. 
 
You asked the Plan to pay for 77427. You say that 77427 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says that 77427 is denied because payment for this 
service was included in payment for another service/procedure that has already been adjudicated. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say carriers must pay for a physician's weekly treatment management services under 
code 77427, which represents a weekly unit of treatment management, equaling five fractions or treatment 
sessions. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that in this case, records appear to indicate that five radiation treatments 
were planned, beginning on the billed date of service, May 8, 2023. Since one unit of 77427 represents five 
treatments, and one unit of 77427 was billed, the claim is correctly requesting payment for the five treatment 
sessions which began on May 8, 2023. The Plan did not provide proof of any other claim or service billed for 
this enrollee. As such, we are unable to determine if the Plan is correct that payment for 77427 was included in 
payment for another service that has already been adjudicated. Also of note, the claim image included in the 
case file is not clearly legible in its entirety, therefore we are unable to confirm if the provider included notes 
on the original claim documenting the number of fractions for which they were seeking payment. Therefore, 
we decided that the Plan has to pay for code 77427, defined as radiation treatment management, five 
treatments, billed on May 8, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report (comprehensive 
hereditary pharmacogenomic 
testing) provided on July 24, 2023. 
 
You asked the Plan to pay for the GeneDose Genetic Response Report. You say that the service was medically 
necessary. The Plan denied your request. The Plan says there is no documentation from the provider 
documenting the drugs being considered for use, and no documentation to how the results will impact 
treatment. 
 
The Plan follows Medicare rules. Medicare rules say that this service is considered medically necessary when 
the criteria listed in the Medicare Rules section is 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 GeneDose Genetic Response Report. 
Our reviewer says that the service was not medically necessary. Our physician reviewer found there is no 
documentation from the provider documenting the drugs being considered for use, and no documentation to 
how the results will impact treatment. 
 
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 GeneDose Genetic Response Report have not been met. Therefore, we 
decided that the Plan does not have to pay for the GeneDose Genetic Response Report (comprehensive 
hereditary pharmacogenomic 
testing) provided on July 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 needs continued medical daily 
supervision due to uncontrolled pain and hypertension. The Plan denied your request. The Plan says the 
enrollee's issues are stable and do not complicate care in the current setting.  
 
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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have 
a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, 
the documentation doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to 
regain or maintain his functional status. The enrollee can receive further services 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 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 a LifeAlert system.  
 
You asked the Plan to pre-approve a LifeAlert system. You say that you were extremely ill over the summer 
and have fallen multiple times. The hospital advised you that you should have this item. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that telephone alert systems are not 
covered because they are considered emergency communications systems that do not serve a diagnostic or 
therapeutic purpose. The requested LifeAlert system is a telephone alert system. While this item may be 
appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that 
the Plan does not have to pre-approve a LifeAlert system.