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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
services in an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
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 an IRF admission and services.
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 the IRF admission is medically necessary. You say 
this is highly recommended by your doctor, and you need to have therapy to heal. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting have not been met. 
 
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 your nursing, rehab, and medical needs do not require an acute 
hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. While you may benefit 
from physical and occupational therapy, your rehabilitation needs can be provided in a lower intensity and 
alternate setting such as in a skilled nursing 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management services coded 99396 provided on October 4, 2022. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine reevaluation and management 
services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services are not payable as billed. 
 
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 99396 is periodic comprehensive preventive medicine 
reevaluation and management of an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic 
procedures, established patient; 40-64 years. 
 
We find that CPT code 99396 is not supported in the medical record. Specifically, this service was billed with a 
place of service 10 (Telehealth provided in patient's home). This means this was not the most appropriate 
service code to be billed for the place of service 10. The claim is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the periodic comprehensive preventive medicine 
reevaluation and management services have not been met. Therefore, we decided that the Plan does not have to 
pay for the periodic comprehensive preventive medicine reevaluation and management services coded 99396 
provided on October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82656, 83520, 87338) provided on September 
6, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. 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 (82656, 83520, 87338) provided on September 6, 2022.
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. The Plan denied your request. The Plan says the 
enrollee is receiving medically necessary acute and/or critical care and does not have clinical conditions that 
cannot be appropriately treated in the current hospital. There are no issues for which LTACH may offer a 
therapeutic advantage. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a spinal cord stimulator. 
 You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the requested 
service. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the 
conditions listed have been 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 pre-approve this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that this enrollee has failed back 
surgery syndrome. Her pain has failed to be adequately controlled with conservative measures including 
medications, and epidural steroid injections. She had a spinal cord stimulator trial in February 2023 with  
60-70% relief of the pain and increased functional abilities. A multidisciplinary evaluation including a 
psychological evaluation has not been submitted. Medicare rules require a psychological evaluation by a 
licensed clinical psychologist or psychiatrist. At this time, this request is deemed not medically 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the implantation of a spinal cord stimulator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 75736 and 75774 provided on July 29, 2022. 
 
You asked the Plan to pay for procedure codes 75736 and 75774. You say that the medical records support the 
use of modifier XU with codes 75736 and 75774. The Plan denied your request. The Plan says that the services 
are not covered as billed. 
 
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 codes 
75736 and 75774 are column II codes to column I code 37244; however, 75736 and 75774 were billed with a modifier. 
 
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 procedure codes 75736 and 75774. Our reviewer says that 
the medical records support the use of modifier XU with codes 75736 and 75774. Our reviewer found the use 
of procedure codes 75736-XU and 75774-XU are permitted by CMS in unusual circumstances when 
angiographic procedures are complicated beyond 37244.  This enrollee was found to have an active bleeding 
site from the superior gluteal artery which required embolization to stop the bleeding. This is an unusual 
location for retroperitoneal bleeding and required more time and expertise than the usual case and thus these 
modified codes in addition to the already paid code 37244 are supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 75736 and 75774 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 75736 and 75774 provided on July 29, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 15, 2020, 
through November 19, 2020, and billed with diagnosis code I50.23. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis I50.23 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of I50.23. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code I50.23-acute on chronic 
systolic heart failure. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the secondary 
diagnosis of I50.23, acute on chronic systolic heart failure. Our physician reviewer found the member did not 
report shortness of breath, dyspnea, tachycardia, rales or rhonchi, or worse peripheral edema beyond baseline. 
The workup revealed cardiomegaly, normal right ventricular systolic function, severe biatrial enlargement, 
severe tricuspid regurgitation (baseline). The member's heart failure was not worse than normal baseline. 
Therefore, secondary diagnosis code I50.23-acute on chronic systolic heart failure is not the appropriate 
secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 15, 2020, through November 19, 2020, and billed with 
diagnosis code I50.23.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 21, 2021, to July 
31, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis codes I21.A1 and N39.0, 
described as myocardial infarction due to demand ischemia, myocardial infarction secondary to ischemic 
imbalance; urinary tract infection, site not specified. We asked our physician reviewer to carefully review the 
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 
pay for the inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does 
not support the billed codes. Our physician reviewer found the enrollee is an 87-year-old female who was 
treated in the hospital. She was diagnosed with calculus of bile duct without cholangitis or cholecystitis with 
obstruction. The stone was extracted. The records showed that the enrollee didn't report symptoms suggestive 
of a urinary tract infection. Troponin was mildly elevated described as "flat troponin" due to "strain" not 
ischemia and electrocardiogram was negative for ischemia. The enrollee had no anginal symptoms.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 21, 2021, to July 31, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from October 9, 2022, to October 12, 2022. 
 
You asked the Plan to pay for the inpatient stay. You say that the documentation supports this inpatient 
admission as reasonable and medically necessary, and within the accepted standards of clinical care. The Plan 
denied your request. The Plan says that the enrollee does not meet medical necessity for inpatient status. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 stay. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found the record showed that at the time of inpatient admission the admitting physician reasonably expected 
that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) 
would span two midnights. 
 
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 stay have been met. Therefore, we decided that the Plan has to pay 
for the inpatient stay provided from October 9, 2022, to October 12, 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: 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 requested services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of the requested 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 that there is no documentation provided indicating the medical necessity for an 
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital.  
 The does not enrollee require services at the LTACH that are not available at the acute care hospital where 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the replacement face mask interface (A7031) and disposable filter 
(A7038) provided on September 28, 2022. 
 
You asked the Plan to pay for the replacement face mask interface and disposable filter. You say that these 
items were approved on July 22, 2022. The Plan denied your request. The Plan says that these services were 
not authorized by a network/primary care provider. 
 
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 records do not support that these items were not authorized. This means that 
the Plan has not provided a valid reason for denying payment of the replacement face mask interface and 
disposable filter. Specifically, within the records provided there is an authorization showing these items were 
approved and valid from July 22, 2022, to December 31, 2022. This timeframe includes this September 28, 
2022, date of service which is at appeal. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the replacement face mask interface (A7031) and disposable filter (A7038) 
provided on September 28, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray for evaluation of swallowing function (74230) 
provided on April 19, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this claim should be covered. The Plan denied your 
request. The Plan says insufficient information was provided to review this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the x-ray have been met. In this case 
the Plan made multiple attempts to obtain information to determine how the enrollee came to the servicing 
provider, and whether the services are medically necessary. This information was not provided. Without this 
information we are unable to verify that the requested services were medically reasonable and necessary. 
Therefore, we decided that the Plan does not have to pay for the x-ray for evaluation of swallowing function 
(74230) provided on April 19, 2022.