Persius/hicric huggingface dataset:
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 you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the requested IRF 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 your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
at an intensive rehabilitation therapy program. 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 inpatient 
rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain your functional status. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient clinic visit provided from July 
27, 2021, to October 26, 2021. 
 
You asked the Plan to waive the copayment for the outpatient clinic visit. You say that the services should be 
covered with a $30 copayment for laboratory services. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 $100 
copayment for Outpatient hospital services.  
 
 
 You have been asked to pay a $778.67 copayment for eight outpatient clinic visits. This copayment includes 
your laboratory work. Outpatient clinic visits fall within the Outpatient hospital services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an outpatient clinic visit provided from July 27, 2021, to 
October 26, 2021.
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 you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the requested IRF 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 documentation does not support that the complexity of your nursing, medical 
and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that you require at least 3 hours a day /5 days a week, 
or 15 hours over 7 consecutive days, of therapy services.  It is not clear 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the preventive physical exam provided on October 21, 2021. 
 
You asked the Plan to pay for the preventive physical exam. You say that you have only had an annual 
wellness visit along with a telehealth visit. You do not feel that either of these should be counted as your full 
physical. The Plan denied your request. The Plan says that you received a preventive visit on September 10, 
2021, meaning that this benefit was exhausted for 2021. 
 
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 documentation shows that the examination provided on September 10, 
2021, was a telehealth visit and was billed with code 99343. This code is defined as "Home visit for the 
evaluation and management of a new patient, which requires these 3 key components: A detailed history; A 
detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of 
care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of 
moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family." 
 
We find that there is nothing in the definition of this code which would support that this was a preventive visit. 
In addition, the diagnosis codes that were reported on this claim were not able to be reviewed. Moreover, we 
find that a full physical exam is not possible in a telehealth visit. As such, the enrollee is not shown to have 
received the annual routine physical exam listed as covered in the contract. Therefore, we decided that the Plan 
has to pay for the preventive physical exam provided on October 21, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on February 4, 
2019, and billed under code 95939. 
 You asked the Plan to pay for this service. You say that this claim should be paid by the plan. The Plan denied 
your request. The Plan says Current Procedural Terminology (CPT) code 95939 26 (1 unit) remains not 
supported. CPT code 95939 represents Central motor evoked potential study (transcranial motor stimulation); 
in upper and lower limbs. The medical records submitted do not include a procedure note for the billed date of 
service; therefore, the billed service cannot be verified. Of note, the submitted documentation included 
procedure notes for date of service February 21, 2019, and February 4, 2019. It is noted that multiple 
attempts were made to contact the provider for additional information.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  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. 
 
Based on the records provided, there are insufficient records to support the services billed. Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided to the enrollee on February 4, 2019, and billed under code 95939.
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 you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not 
meet Medicare criteria for coverage of the IRF 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 members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The member continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that she would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no 
indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his/her 
functional status.  The member can receive further services at a lower level of care. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided on June 1, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that prior authorization is not required for an office visit. 
The Plan denied your request. The Plan says the claim was denied due to non-participating provider billing for 
unauthorized services. The Plan also says that the member does not have out of network benefits and the 
servicing provider is not a participating provider with the Plan. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on June 1, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician services provided to the enrollee from September 1, 2021 to 
September 15, 2021. 
 
You asked the Plan to pay for the services billed. . You say that this claim should be paid. The Plan denied your 
request. The Plan says that  
 
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 case file submitted gives no clear explanation as to the 
services denied other than stating does not meet coding standard. The Plan is responsible for providing a 
concise case file to the IRE. Therefore, we decided that the Plan has to pay for physician services provided to 
the enrollee from September 1, 2021 to September 15, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that you would like reconsideration 
because the requested injection is medically necessary. The Plan denied your request. The Plan says the 
member does not meet Medicare criteria for coverage. 
 
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 epidural steroid injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the member has an acute exacerbation of her underlying chronic back pain 
syndrome. Repeat injection before the 3 month interval is not indicated per Medicare LCD and an ESI is not 
indicated for acute pain. 
 
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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided on April 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that prior authorization is not required for an office visit. 
The Plan denied your request. The Plan says the member does not have out of network benefits and the services 
provider is not a network provider with the Plan. The Plan also says that the services were unauthorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on April 22, 2021, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on November 
11, 2021. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that a mistake was made by the 
technician resulting you needing to have additional tests. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
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 $30 
copayment for outpatient diagnostic tests, not otherwise specifically listed in the Evidence of Coverage. 
 
 The records show you had a breast ultrasound. You have been asked to pay a $30 copayment for a breast 
ultrasound. A breast ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a breast ultrasound 
provided on November 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tramadol HCL (CPT code J8499), for the enrollee. 
 
You asked the Plan to pre-approve the medication. You say that the medication is needed. The Plan denied 
your request. The Plan says the requested drug is intended for enrollee self-administration. 
 
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 tramadol HCL (CPT code 
J8499), for the enrollee.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin D testing provided on June 1, 2021. 
 
You asked the Plan to pay for the vitamin D testing. You say that the lab report and order shows medical 
necessity. The Plan denied your request. The Plan says this was a screening test. 
 
The Plan must follow Medicare rules. Medicare rules say that vitamin D testing is covered for various 
signs/symptoms and diseases as listed in the Medicare rules section. 
 
We looked at the file and Medicare rules. There are no records to support the reason this testing was ordered 
and none of the reported diagnoses are listed as covered. Based on this information, we decided that Medicare 
rules for coverage of the vitamin D testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the vitamin D testing provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement (36246) provided on May 
27, 2021. 
 
You asked the Plan to pay for the selective catheter placement. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not support the service 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 36246 is selective catheter placement, arterial system; 
initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family. 
 
 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 selective catheter placement. Our reviewer says that the 
documentation does not support the billing of modifier 59 with CPT code 36246. In regards to the submitted 
(CPT) code of 36246-59, the physician inserts a needle through the skin and into an underlying artery, usually a 
lower extremity artery, and threads a guidewire through the needle and into the artery. The needle is removed. 
The wire is threaded into the specific vessel. A catheter follows the wire into the artery branch. The wire is 
removed. In 36246, the catheter travels to a second order artery. Once the procedure is complete, the catheter is 
removed and pressure applied to stop bleeding at the injection site. Our reviewer found the documentation 
supports that CPT code 36246 is inclusive to the main procedure. 
 
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 selective catheter placement have not been met. Therefore, we decided that 
the Plan does not have to pay for the selective catheter placement (36246) provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on March 25, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the member has no out of network benefits, and the services provider is not 
a participating provider with the Plan. 
 
 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on March 25, 
2021, by an out-of-network (OON) provider.