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

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee is no longer a threat to self or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The file shows that continued inpatient services beyond February 25, 2022, were requested. 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 requested services. Our physician reviewer found that active treatment was not taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question.
Based upon review the records, the enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of safety. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
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 do not require at least 3 hours a day/5 days a week, or 15 hours over 7 
consecutive days, of therapy services. You will not be able to fully participate in therapy, however the services 
can be provided 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 the moderate sedation services rendered on June 21, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status for the first 15 minutes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes.
Billed procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment.
Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on June 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the thoracic 
spine (72128) 
 
You asked the Plan to pre-approve the CT scan services. You say that this imaging service is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
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 the CT scan services. Our reviewer says 
that this imaging service is medically necessary. Our physician reviewer found that the enrollee had no 
abnormal physical exam findings and had not completed any course of conservative treatment (physical 
therapy). There was no clinical rationale for a thoracic CT scan. The review has determined that the requested 
CT Scan was not medically reasonable or 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 CT scan services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the computed tomography (CT) scan of the thoracic spine (72128)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vimpat (lacosamide) 150mg tablets. 
 
You asked the Plan to pre-approve the Vimpat tablets. You say that this is medically necessary. The Plan 
denied your request. The Plan says this oral drug cannot be covered by Medicare Part B. 
 
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 Vimpat (lacosamide) 
150mg tablets.  
 
Benefits for the Vimpat tablets 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lumbosacral x-ray (72100), a tissue 
pathology exam (88304), and outpatient hospital services including an arthrodesis surgical procedure (22630) 
provided on September 7, 2021, to September 9, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital and observation services. You say that the 
procedures you received during your hospital stay were necessary for your back surgery. The Plan denied your 
request. The Plan says the cost-sharing was applied 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 $55 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. Your contract also says that 
you must pay a $5 copayment for Outpatient Hospital Services and a $375 copayment for Outpatient Surgery.  You have been asked to pay a $250.94 copayment for outpatient hospital and observation services. The 
services at issue fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies, Outpatient 
Hospital Services, and Outpatient Surgery benefit categories. You have been asked to pay less than the required 
cost-share outlined in your EOC. 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 lumbosacral x-ray 
(72100), a tissue pathology exam (88304), and outpatient hospital services including an arthrodesis surgical 
procedure (22630) provided on September 7, 2021, to September 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a morphine sulfate injection (J2274) and a 
clonidine hydrochloride injection (J0735) provided on October 4, 2021. 
 
You asked the Plan to waive the coinsurance for the Medicare Part B injections. You say that you are unable to 
pay your cost-share and do not want to be responsible for paying the charges. You say you want assistance in 
paying your cost-share amount. The Plan denied your request. The Plan says the coinsurance was applied 
correctly as outlined by your contract with the Plan.  
 
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 20% 
coinsurance for Medicare Part B Prescription Drugs.  
 
 You have been asked to pay a 20% coinsurance in the amount of $222.08 for Medicare Part B injections. See 
below for a breakdown of your cost-share. 
Morphine sulfate injection (J2274)  
Allowed Amount = $942  20% coinsurance = $188.40 
Clonidine hydrochloride injection (J0735)  
Allowed Amount = $168.40  20% coinsurance = $33.68 
Total Cost-Share 
$188.40 + $33.68 = $222.08 
 
The services at issue fall 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 coinsurance for a morphine sulfate injection (J2274) and a clonidine hydrochloride 
injection (J0735) provided on October 4, 2021.
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 admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee appears to be improving but still requires short-term acute care services 
that can safely be administered at the current facility until stable for a lower level of care. There are no services 
at the LTACH that the enrollee requires that are not already available and covered at the current facility. 
Transfer to a lower level of care may be considered when treatment has completed.  
 
 
 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: 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 needs IRF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements 
for approval. 
 
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 review has determined that the complexity of the enrollees nursing, medical 
and rehabilitation needs do 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. There is not a reasonable 
expectation that this 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable sensors and transmitter for a continuous 
glucose monitor (CGM). 
 
You asked the Plan to pre-approve continuous glucose monitor supplies. You say that you need better control 
of your glucose monitoring. The Plan denied your request. The Plan says you do not meet the Medicare criteria 
for the requested continuous glucose monitor. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 continuous glucose monitor supplies. 
Our reviewer says that you do not meet the Medicare criteria for the requested continuous glucose monitor supplies. Our physician reviewer found you use insulin once daily. The record does not show that glucose is 
checked frequently and adjustments are made based upon the test results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous glucose monitor supplies have not been met. Therefore, we decided 
that the Plan does not have to pre-approve disposable sensors and transmitter for a continuous glucose monitor 
(CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services. The enrollee has limited ability to participate in and benefit from skilled therapy services. It is not 
medically reasonable and necessary to provide skilled therapy services on a daily basis on an inpatient basis, in 
a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 21, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the requested service code is not substantiated by the clinical documentation. 
 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 25215 
is a column II code to column I code 25444. 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 surgical services provided to the enrollee on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81201, 81295, 81298, 81317, 81403, 81404, 
81405, 81406) provided June 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single genetic testing 
panel. Based on this information, we decided that Medicare rules for coverage of the lab services have not been 
met. Therefore, we decided that the Plan does not have to pay for lab services (81201, 81295, 81298, 81317, 
81403, 81404, 81405, 81406) provided June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy (45385) provided on February 4, 2021. 
 
You asked the Plan to pay for the colonoscopy. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the provider must bill the primary payer 
before they will pay for these services. 
 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider in the Reconsideration Determination to bill the primary insurer listed. As the secondary insurer, the 
Plan cannot be held responsible for the colonoscopy until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the colonoscopy (45385) provided on 
February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on November 25, 
2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services rendered on May 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99053 has a status indicator of B and no 
separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services 
rendered on May 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the requested service code is not substantiated by the clinical documentation. 
 
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 64708 
is a column II code to column I code 27650. 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 surgical services provided to the enrollee on August 4, 2021.