Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network specialist visit provided on 
October 29, 2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you were made to see the nurse 
practitioner instead of your doctor so the charge should be waived. The Plan denied your request. The Plan says 
the copayment applied is correct. 
 
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 $55 
copayment for each out of network Medicare covered individual or group therapy visit.  
 
 
 
 You have been asked to pay $55 copayment for specialist visit. Specialist visits fall within the Outpatient 
Mental Health Care 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 out of network 
specialist visit provided on October 29, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT), abdomen and pelvis; without contrast 
material in one or both body regions, followed by contrast material(s) and further sections in one or both body 
regions (74178) and CT, thorax, diagnostic; with contrast material(s) (71260). 
 
You asked the Plan to pre-approve CT scans of the abdomen, pelvis and chest. You say that the enrollee needs 
these CT scans. The Plan denied your request. The Plan says that the documentation does not show abnormal 
test findings or exam findings that show the need for the CT scans. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CT scans of the abdomen, pelvis and 
chest. Our reviewer says that CT scans of the abdomen, pelvis and chest are medically reasonable and 
necessary. Our physician reviewer found that this enrollee has an IgM monoclonal gammopathy. This differs 
from multiple myeloma of other subtypes as falls under Waldenstom's. A CT scan is part of the initial work-up 
to look for lymphadenopathy per the National Comprehensive Cancer Network (NCCN) Guidelines. The 
service is reasonable and 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 CT scans of the abdomen, pelvis and chest have been met. Therefore, we 
decided that the Plan has to pre-approve computed tomography (CT), abdomen and pelvis; without contrast 
material in one or both body regions, followed by contrast material(s) and further sections in one or both body 
regions (74178) and CT, thorax, diagnostic; with contrast material(s) (71260).  
 
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 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 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have chronic medical problems and chronic back pain. Your pain is likely multi-
factorial. You are able to ambulate and do your exercises without hands on support. You do not have an acute 
injury amenable to intensive rehabilitation and you do not have a rehabilitation problem that requires an 
inpatient stay. Your care needs may reasonably be addressed at an outpatient or home care 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: 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 an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the medical criteria for an IRF admission has 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 per enrollee's own performance with the low level of rehabilitation he can progress 
without intensive rehabilitation.  
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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have complex rehabilitation needs, does not require frequent 
oversight from a physiatrist. She has no contractures or autonomic instability. She cannot participate in nor 
benefit from intensive rehabilitation. Criteria per chapter 1 Medicare benefit manual not met. 
 
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 pay for physical therapy (PT) services provided from February 17, 
2022, to March 8, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the PT services. You say that the enrollee is entitled to all Medicare approved 
services. The Plan denied your request. The Plan says services from out-of-network providers are not covered 
unless preauthorized. 
 
  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 physical therapy (PT) services provided from 
February 17, 2022, to March 8, 2022, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for IRF services. The 
Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting. 
With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level 
of care can be determined. 
 
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 enrollee is de-conditioned due to acute illness. The enrollee does not have 
complex rehabilitation needs requiring frequent physiatry oversight. The enrollee's response to therapy also 
indicates insufficient capacity to participate in intensive rehabilitation. 
 
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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is not likely to return to the community. Her family was awaiting 
placement in a facility at time of hospitalization. She has low endurance and modest rehabilitation needs. She is 
deconditioned chronically and following an acute illness. She does not have complex needs requiring frequent 
physiatry oversight. Her response to limited therapy in the hospital, moving promptly to underscore her 
capacity to improve without intensive rehabilitation. At the same time her limited endurance also underscored 
her inability to participate in intensive rehabilitation. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on March 1, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is 
not eligible for payment. 
 
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 29877 is a column II code to column I code 29881 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services 
provided on March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 23, 2021, through 
June 28, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the 
completeness of care, stability at discharge, and adequacy of discharge planning cannot be determined from the 
records provided in this case. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee had been discharged on June 19, 2021 but returned to the emergency 
department (ED) on June 20, 2021 with agitation and delirium. She was admitted and continued on intravenous 
antibiotics. The review indicates that the record showed that at the time of the inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from June 23, 2021, through June 28, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at home and needs a higher level of 
care for safety. The Plan denied your request. The Plan says IRF care is not supported. 
 
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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of lower extremity arteries or arterial bypass 
grafts identified with code 93926 provided on March 27, 2022. 
 
You asked the Plan to pay for the duplex scan of lower extremity arteries or arterial bypass grafts. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
 
 
 
 We find that 2 units of CPT code 93926 are not supported in the medical record. The medical record only 
supports 1 units of CPT code 93926. Based on this information, we decided that Medicare rules for coverage of 
the duplex scan of lower extremity arteries or arterial bypass grafts have not been met. Therefore, we decided 
that the Plan does not have to pay for the duplex scan of lower extremity arteries or arterial bypass grafts 
identified with code 93926 provided on March 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided August 22, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that your policy covers emergency and 
ambulance services when out-of-area. The Plan denied your request. The Plan says this service is not covered 
when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on August 22, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided August 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital services provided from 
March 5, 2022, to March 6, 2022. 
 
You asked the Plan to waive the cost share for the services provided. You say that you should have full 
coverage. The Plan denied your request. The Plan says the cost sharing cannot be waived. 
 
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 10% 
coinsurance for inpatient hospital care.  
 
You have been asked to pay a 10% coinsurance for the inpatient services. The services fall within the inpatient 
hospital care 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 cost share for the inpatient hospital 
services provided from March 5, 2022, to March 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit and service(s) provided 
between 10:00 PM and 8:00 AM at 24-hour facility billed with procedure code 99053 provided on January 2, 
2022.  
You asked the Plan to pay for the emergency department visit and service(s) provided between 10:00 PM and 
8:00 AM at 24-hour facility billed with procedure code 99053. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the emergency department visit is included in a global surgery 
period and procedure code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
Review of the file shows that the emergency department visit was included within the 10-day global surgery 
period of surgery code 10061 (Incision and drainage of abscess). This code was not billed with an appropriate 
modifier for this to be covered separately.  
 
Also, we find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of the emergency department visit and Service(s) provided between 10:00 PM and 8:00 AM at 24-
hour facility billed with procedure code 99053 have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department visit and service(s) provided between 10:00 PM and 8:00 AM at 24-
hour facility billed with procedure code 99053 provided on January 2, 2022.