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 you need skilled nursing care because you are 
bedridden and in pain. The Plan denied your request. The Plan says your record does not show that you require 
daily skilled nursing or skilled therapy in a SNF setting.  
 
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 do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have complex wound care, intravenous 
(IV) antibiotics, enteral feedings or other skilled nursing needs during these dates that require a SNF admission. 
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 skilled nursing facility setting. As a practical matter your needs do not require the necessary services 
on an inpatient basis in a SNF. Your needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve 12 physical therapy visits. You say that you are requesting an expedited 
reconsideration stating the enrollee reports steady gains from physical therapy but needs to continue care to 
reach their functional rehabilitation goals. The Plan denied your request. The Plan says the additional physical 
therapy visits are denied as 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 therapy services. 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 the request for additional therapy does not provide rationale based on 
the enrollee's persistent pain despite more than 76 visits. The enrollee has a chronic condition and is able to do 
a home exercise program and does not require continued input from a skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 physical therapy visits.
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 a skilled nursing facility does not offer adequate care 
for the enrollee. The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation care. There is not a reasonable expectation that the 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 10, 2023, to 
February 8, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 10, 2023, to 
February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 90471 and 90715 billed for date of service January 19, 
2023. 
 
You asked the Plan to pay for codes 90471 and 90715. You say that these services were emergent in nature and 
provided in good faith. The Plan denied your request. The Plan says these two codes are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, code 90471 has a status indicator of QI, meaning that it is 
a STV-packaged service.  This disputed code was billed on the same claim with a code that has a status 
indicator of S, T, or V.  This means that code 90471 is not separately payable. 
 
In relation to code 90715, Medicare rules state that services that have a status indicator of N on Addendum B-
OPPS Payment are never separately payable.  Code 90715 has a status indicator of N, so no separate payment 
can be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 90471 and 90715 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes 90471 and 90715 billed for date of service January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen tank refills. 
 
You asked the Plan to pre-approve oxygen tank refills. You say that you need new tanks because they are not 
something you can own- they need to be refilled when they are out of oxygen. The Plan denied your request. 
The Plan says it does not have to pay or pre-approve additional oxygen refills because it has already paid the 
36-month rental for your oxygen equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that that oxygen equipment is paid based on a 36-
month rental. After the 36 months has passed, the supplier who provided the equipment during the 36th rental 
month is required to continue to provide the equipment, accessories, contents (if applicable), maintenance, and 
repair of the oxygen equipment during the 5 year reasonable useful lifetime of the equipment. 
 
In other words, this means that your oxygen supplier is required to continue to provide you with oxygen 
contents after the 36th month of rental, but the Plan doesn't have to pay for any additional contents because the 
cost of additional contents was already built into the 36 monthly payments made to the oxygen supplier.  You 
may contact your oxygen supplier for more information about continuing delivery of your oxygen contents. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of oxygen tank refills have not been met. Therefore, we decided that the Plan does not have to pre-
approve oxygen tank refills.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on November 30, 2022.

You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services provided on November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service December 
16, 2022. 
 You asked the Plan to pay for procedure code 87481. You say that this code should be unbundled. The Plan 
denied your request. The Plan says payment for code 87481 is bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87481 
is a column II code to column I code 87801. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87481 billed for date of service December 16, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the skin graft procedure provided on 
January 13, 2023. 
 
You asked the Plan to reduce the copayment for the skin graft procedure. You say that the surgery did not take 
place at a hospital. 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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $325 copayment for the skin graft procedure. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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. The record shows you received 
services from a hospital. Therefore, we decided that the Plan does not have to reduce the copayment for the 
skin graft procedure provided on January 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 28, 2022, 
through March 29, 2022. 
 You asked the Plan to pay for the home health services. You say that the claim should be paid due to medical 
necessity. 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 January 29, 2022. The NOA was not received by the Plan until May 13, 
2022. 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 the home health services 
provided from February 28, 2022, through March 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 6, 2022, 
through December 22, 2022.  
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary and 
correctly billed.  The Plan denied your request. The Plan says the FIPs code reported is not valid.  
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must include value code 85 
where the FIPS code must be reported. 
 
We looked at the file and Medicare rules. Review of the code reported in value code 85 shows that it is not a 
valid FIPS code. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from December 6, 2022, through December 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the 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 that you do not have complex nursing or rehabilitation needs. 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 you 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says that ongoing home health services are no longer 
required. 
 
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 that the 
enrollee has no ongoing skilled nursing needs. 
 
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 seven home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion supplies provided between September 20, 
2022, and September 26, 2022. 
 You asked the Plan to pay for the infusion supplies. You say that this should be paid as the intravenous (IV) 
infusion supplies must be reimbursed since the enrollee was receiving IV infusions in the home.  The Plan 
denied your request. The Plan says this claim was denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of home infusion services is allowed 
only for services related to administration of drugs through a DME pump.  
 
We looked at the file and Medicare rules. The file shows that the drug being infused was vancomycin. This 
drug is not administered through a DME pump. As such, the supplies and other professional services related to 
the infusion in the home are not covered by Medicare. Based on this information, we decided that Medicare 
rules for coverage of the infusion supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for the home infusion supplies provided between September 20, 2022, and September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).  
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says that the upgraded electronics are not 
medically necessary. 
 
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 pre-approve the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has adequate upper body strength to manage standard power drive 
controls. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2313, E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance . You say that you request 
for review of the enclosed documentation to support medical necessity of the prescribed Flexitouch PCD in 
treating the enrollee's lymphedema. The Plan denied your request. The Plan says the enrollee does not meet the 
LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic 
compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0667).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cataract surgery provided on January 24, 2023.

You asked the Plan to reduce the copayment for the cataract surgery. You say that you were only expecting a $35 copayment. 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 $350 copayment for in-network outpatient surgery, including services provided at ambulatory surgical centers.

You have been asked to pay a $350 copayment for the cataract surgery. This item/service falls within the in-network outpatient surgery, including services provided at ambulatory surgical centers 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. However, since the allowed amount is less than the standard copayment, you only owe $284.47. Therefore, we decided that the Plan does not have to reduce the copayment for the cataract surgery provided on January 24, 2023.