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

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 13, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service July 13, 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 IRF care should be covered for the patient. The Plan 
denied your request. The Plan says the patient's needs can be met at a lower level of care. 
 
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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not require intensive physician and nursing oversight in an IRF. While the patient may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the patient requires this therapy on an intensive IRF level. 
 
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 pre-approve a consultation to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the evaluation and management service. You say that the requested provider 
performed your last shoulder surgery. You say that you trust them. You also say that you would like to go back 
to them. The Plan denied your request. The Plan says services must be provided in-network. The Plan also says 
there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there are 
network providers available who can provide the items/services at issue in this appeal. We found no exception 
that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not 
have to pre-approve a consultation to be provided by an out-of-network (OON) provider.  
 No continuity of care issue has been identified in this case.
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 LTACH services are medically 
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an 
LTACH are not met. The enrollee should remain in the current acute care hospital until treatment is finished 
and they are stable for transfer to a lower level of 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 there is no documentation provided indicating medical necessity for admission to 
an LTACH. 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 he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee does require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a 
week, or 15 hours over seven consecutive days. As of 11/8/2022, the enrollee was requiring contact guard 
assistance with bed mobility and minimal assistance when ambulating 280 feet with a walker. An occupational 
therapy note dated 11/8/2022 indicated that the enrollee had visual deficits and required moderate assistance 
with transfers. Speech pathology noted that he had difficulty with visual processing on 11/8/2022. The enrollee 
has had a significant functional decline from his baseline level of function and would benefit from the intensity 
of therapies provided on acute inpatient rehabilitation. He continues to have weakness, impaired mobility and 
function, and visual impairment due to his stroke. Therefore, the acute inpatient rehabilitation admission is 
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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx testing provided on April 1, 2022. 
 
You asked the Plan to pay for the SelectMDx testing. You say that this is a necessary test in order to judge the 
likelihood of a positive prostate biopsy. The Plan denied your request. The Plan says this is not medically 
necessary based on the criteria. 
 
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 SelectMDx testing. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation indicates that the SelectMDx test is designed for patients who have elevated 
prostate-specific antigen (PSA) levels and have not yet had biopsy. ConfirmMDx is the test used to determine 
if a repeat biopsy is necessary after initial negative biopsy. This enrollee already had a prostate biopsy. As such, the use of the SelectMDx testing in this situation is not considered reasonable and 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 SelectMDx testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the SelectMDx testing provided on April 1, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met a 
lower level of care such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for abdominal pain, hydronephrosis and encephalopathy. The enrollee's medical problems are stable, and 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. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity angiography and revascularization. 
 
You asked the Plan to pre-approve lower extremity angiography and revascularization. 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 follows Medicare rules. Medicare rules say that vascular stenting of lower extremity arteries 
performed for clinically significant occlusive vascular disease will be considered medically reasonable and 
necessary for a patient under certain circumstances. 
 
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 lower extremity angiography and 
revascularization. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is insufficient documentation to support the medical necessity for lower extremity angiography and 
revascularization in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity angiography and revascularization have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lower extremity angiography and 
revascularization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prosthesis replacement received on April 4, 2022. 
 
You asked the Plan to pay for the services. You say that you do not understand why the claim denied. The Plan 
denied your request. The Plan says the records do not support the billed service 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the issue is that there is no prescription or letter of medical necessity. Additionally, the patient name 
and address is unrelated to the patient listed on the billed claim. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for prosthesis replacement received on April 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says home health services for daily task, bathing or household chores are not a covered 
benefit. 
 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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the enrollee is 
medically stable without any recent hospitalizations or medical complications. There are no skilled care needs 
therefore the enrollee does not meet medical necessity for services from a home health aide. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for physician services 
provided from July 14, 2021, to November 29, 2021. 
 
You asked the Plan to waive the copayments and coinsurance for the physician services. You say that you paid 
the copayments and the rest of the charges should be 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 $50 
copayment for physician/practitioner services, including doctor's office visits (specialist), a $175 copayment for 
radiological diagnostic services, not including x-rays, and a 20% coinsurance for Medicare Part B prescription 
drugs. 
 
Item/Service Allowed Amount Cost Share per EOC Actual Charges 
Office Visit 7/14/2021 $122.08 $50 $50 
Ultrasound 7/14/2021 $118.43 $175 $118.43 
Office Visit 7/28/2021 $33.66 $50 $33.66 
Ultrasound 7/28/2021 $118.43 $175 $118.43 
Office Visit 8/2/2021 $71.19 $50 $50 
Ultrasound 8/2/2021 $118.43 $175 $118.43 
Office Visit 9/1/2021 $1,719.20 $50 $50 
Injection 9/1/2021 $3.90 $0.78 $0.78 
Ultrasound 9/3/2021 $118.43 $175 $118.43 
Ultrasound 9/9/2021 $118.43 $175 $118.43 
Office Visit 9/13/2021 $71.19 $50 $50 
Ultrasound 9/13/2021 $118.43 $175 $118.43 
Office Visit 9/29/2021 $47.81 $50 $47.81 
Ultrasound 9/29/2021 $118.43 $175 $118.43 
Office Visit 10/13/2021 $47.81 $50 $47.81 
Ultrasound 10/13/2021 $118.43 $175 $118.43 
Office Visit 11/29/2021 $71.19 $50 $50 
Ultrasound 11/29/2021 $118.43 $175 $118.43 
Total:  $1975.78 $1445.93 
 
You have been asked to pay a total of $1,445.93 for the physician services. The office visits fall within the 
physician/practitioner services, including doctor's office visits (specialist) benefit category. The ultrasounds fall 
within the radiological diagnostic services, not including x-rays benefit category. The injection falls within the 
Medicare Part B prescription drugs 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 copayments and 
coinsurance for physician services provided from July 14, 2021, to November 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the enrollee presented to the 
emergency room and requires inpatient mental health services as soon as possible. The Plan denied your 
request. The Plan says the enrollee does not have thoughts of harming self or others, and therefore mental 
health services at the inpatient hospital level are not reasonable and necessary. The enrollee can receive the 
necessary care in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 inpatient psychiatric care. Our reviewer 
says that inpatient psychiatric care is not medically necessary. Our physician reviewer found this 46-year-old 
female was admitted to the acute inpatient psychiatric hospitalization on November 7, 2022, with Bipolar 
Disorder. Based upon review of the records provided it was not expected this enrollee would improve in a 
reasonable period of time as she did not have dangerousness to self or others and was not showing any 
auditory/visual hallucinations or any aggressive behaviors. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
as she did not have dangerousness to self or others. The health plans denial of inpatient psychiatric services 
appears appropriate. This enrollee did not appear to require inpatient mental health treatment as she was not a 
danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear 
that active treatment was taking place. It did not appear that the services were reasonably expected to improve 
the patients condition or for the purpose of diagnosis. The doctor was unable to find an individualized 
treatment plan over the entire record as it is not present. It did appear that the records were supervised and 
evaluated by a physician. Based upon review the records provided for the admission of this patient does not 
meet criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to herself 
or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment 
while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve Synvisc One. You say that the requested Synvisc One injection is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan stated in the case file that no medical records were sent with the appeal 
request. However, this contradicts what the Plan has stated in the case narrative that clinical information was 
reviewed by the Plan's medical director. The Plan denied the service stating that less than six months has 
passed since the last injection, however; the Plan provided no evidence that supports this denial. Therefore, we 
decided that the Plan has to pre-approve Synvisc One.  
 
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.