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

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on  
May 27, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87798, 
87481, 87653, 87640, 87641) provided on March 30, 2023. 
 
You asked the Plan to pay for the urine PCR testing. You say that this testing is medically necessary to 
diagnose and treat the enrollee.  The Plan denied your request. The Plan says this testing exceeds the medical 
need of the enrollee.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the urine PCR testing. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture 
and sensitivity. There was no documentation to suggest the PCR testing addition would lead to an improved 
outcome over the standard of care testing alone. Therefore, this testing will be considered not reasonable or 
medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the urine PCR testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) panel (87798, 87481, 87653, 87640, 
87641) provided on March 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 18 units of procedure code 88341 rendered on January 16, 
2023. 
 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 there was no specific rationale for the extra units. 
 
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 88341 is "Immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure)." 
 
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 provided documentation 
describes 18 units of procedure code 88341 were rendered on January 16, 2023. However, the documentation 
did not clearly describe why more than 13 units were needed for this enrollee. Therefore, the additional 
services were not supported as reasonable or necessary. 
 
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 18 units of procedure code 88341 rendered on January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 83520) rendered on 
March 19, 2023. 
 
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 Current Procedural Terminology (CPT) code 83520 remains 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 83520 is "Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified."

 
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 medical records provided does not include sufficient documentation to validate that an Immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified was the test that was performed 
on March 19, 2023. A complete description for the "not otherwise specified code" must be included in the 
medical documentation. Because this documentation is not included, this code cannot be verified. 
 
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 laboratory services (procedure code 83520) rendered on March 19, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 14, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patients medical record. There was no documentation of contact in the patient record. The 
listing of a referring provider on the claim does not satisfy the documentation criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 14, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 28, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patients medical record. There was no documentation of contact in the patient record. The 
listing of a referring provider on the claim does not satisfy the documentation criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466).  
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support the 
need for ventilator. The enrollee does not have documented trial or failure of bilevel positive airway pressure 
(BIPAP). Therefore, a home ventilator is not indicated as best practice 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
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's treating physician is appealing the 
denial of the requested inpatient rehabilitation facility (IRF) services. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval.  
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
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. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee 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: 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 services are medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for admission to a SNF. 
 
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 you are functioning at a home care level. You are unable to perform rehabilitation of 
your arm or use your arm with non-weight bearing status. You do not require and cannot respond to daily 
skilled therapy. You have no daily skilled nursing needs. Therefore, you do not meet the criteria for admission 
to a 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) for tooth #15 provided on May 22, 
2023. 
 
You asked the Plan to pay for D2950. You say that your crown was cracked, and you needed it fixed. The Plan 
denied your request. The Plan says the denied service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
build-up (D2950) for tooth #15 provided on May 22, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional speech therapy visits. 
 
You asked the Plan to pre-approve the 10 additional speech therapy visits. You say that the records provided 
support the need for additional speech therapy visits.  The Plan denied your request. The Plan says the 
requested speech therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 additional speech therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that, after the speech therapy services 
already provided, the records do not support that the complexity of the enrollees conditions are such that the 
skills of a professional therapist are required to achieve further improvement in the patients symptoms or 
functional status. There are no medical notes from the enrollees treating physician which document an order or 
need for additional skilled speech therapy visits. Further utilization of the home exercise program appears 
appropriate at this point.  
 
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 10 additional speech therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 10 additional speech therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you are unable to move around and can't 
drive. You also say that you have upcoming appointments that are medically necessary.  The Plan denied your request. The Plan says your benefit does not cover more than 10 one-way trips per plan 
year. Per the plan records, you have utilized 9 one-way non-emergency transportation trips for this benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. You asked the Plan to approve 11 
additional routine transportation trips for your appointments. However, the Plan offers a transportation benefit 
that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a 
maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 11 additional routine transportation trips (A0100).
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 appealing the denial of the requested 
inpatient rehabilitation facility (IRF) services. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval.  
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for acute kidney injury. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
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. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion therapy provided on February 21, 2023. 
 
You asked the Plan to pay for the infusion therapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for infusion therapy provided on February 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa, a self-administered drug 
 
You asked the Plan to pre-approve a self-administered drug. You say that the requested drug is medically 
necessary for treating overactive bladder and mixed incontinence. The Plan denied your request. The Plan says 
the medication is not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa, a self-
administered drug
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 the enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. 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 enrollee was admitted to the acute care hospital for planned coronary bypass 
grafting procedure complicated by arterial bleed in the rectum requiring blood transfusions, arterial 
embolization, and further complicated by cardiac arrest, and feeding tube placement.   
The enrollee appears to be improving but is still somewhat unstable and requires additional acute care services 
that can safely be provided at the current facility until more stable and appropriate for transfer. The enrollee 
does not require services at the LTACH that are not already available at the current 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 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.