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 IRF care is medically necessary and supported by the 
records provided. The Plan denied your request. The Plan says the records do not show the enrollee can 
participate in therapy three hours a day, five days a week or fifteen hours per week. The Plan says that the 
services needed can be provided safely in other settings. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of tibial fracture after a fall and for care for diabetic foot wounds. The 
enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services provided on December 31, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraspinal chiropractic manipulative treatment 
(98943). 
 
You asked the Plan to pre-approve an extraspinal chiropractic manipulative treatment. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 98943 has a Status Indicator of N on the Physician Fee Schedule. This means that CPT 
code 98943 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of an extraspinal chiropractic manipulative treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an extraspinal chiropractic manipulative treatment (98943).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits (97163, 97110) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve additional PT. You say that the enrollee suffers from significant trismus due 
to surgery and radiation. She was previously seen by the OON PT provider requested. You also say that you 
saw the enrollee in early February and her pain and stiffness has worsened. You believe the PT level of care 
can be provided by the requested provider. The Plan denied your request. The Plan says the medical care the 
enrollee requires, can be provided by a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
additional physical therapy (PT) visits (97163, 97110) to be provided by an out-of-network (OON) 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 you would benefit from IRF care. The Plan denied 
your request. The Plan says you do not meet the Medicare criteria for admission to 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 your 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on January 3, 2022. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says this service is not supported in the record 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the medical record. Without this information, we cannot verify that 30-74 minutes of 
critical care were provided on the date in question. Based on this information, we decided that Medicare rules 
for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for 
critical care, first hour (99291) provided on January 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require IRF care to improve your quality of life. 
The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to 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 your 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 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for nasal/sinus endoscopy services (31276-RT, 31276-LT, 
30140-RT, 30140-LT) provided on January 27, 2022. 
 
You asked the Plan to pay for services billed with codes 31276 and 30140. You say that these services are 
supported as billed in the medical record. The Plan denied your request. The Plan says these services were not 
billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. The rules also say that if a procedure is 
performed bilaterally and the procedure code descriptor does not state that it is a unilateral or bilateral 
procedure, report bilateral surgical procedures on a single claim line with modifier 50 and one (1) unit of 
service. When modifier 50 is required by manual or coding instructions, claims submitted with 2 lines or 2 
units and anatomic modifiers will be denied for incorrect coding. 
 
In this case, the MUE for CPT both codes 30140 and 31276 is 1. The MAI value for this code is 2. You billed 2 
units of this code, exceeding the MUE. In addition, these units were billed with 2 units each with anatomic 
modifiers. Medicare rules requires that each of these services be billed on a single line with modifier 50 to 
report bilaterality. Based on this information, we decided that Medicare rules for coverage of services billed 
with codes 31276 and 30140 have not been met. Therefore, we decided that the Plan does not have to pay for 
nasal/sinus endoscopy services (31276-RT, 31276-LT, 30140-RT, 30140-LT) provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
and additional levels (CPT code(s): 64635 and 64636). 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in pain. The Plan denied your 
request. The Plan says the enrollee's request is not medically necessary because the enrollee's records show 
they do not have at least two (2) medically reasonable and necessary diagnostic medial branch blocks (MBBs), 
with each one providing a consistent minimum of 80% sustained relief of primary (index) pain. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found the enrollee has not had two (2) medically reasonable and necessary diagnostic facet joint procedures at 
left L5-L5, L5-S1, with each one providing a consistent minimum of 80% relief of primary (index) pain (with 
the duration of relief being consistent with the agent used). The review has determined that the medical records 
provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint and additional levels (CPT 
code(s): 64635 and 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 2, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was just your annual wellness 
visit so it should be covered. 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 $15 
copayment per primary care visit or non- preventive services rendered at an annual wellness visit.  
 
 
 
 You have been asked to pay $15 copayment for an office visit. Office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 office visit provided on March 2, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care provided on February 17, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was no longer 
enrolled in hospice on the date of service in this case. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on February 5, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital 
care provided on February 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient hospital clinic visit, and laboratory services 
provided on January 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient hospital clinic visit, and laboratory services. You say that the 
patient presented to this provider for services related to a kidney transplant received on June 25, 2019. You also 
say that continued treatment was rendered for this member. The Plan denied your request. The Plan says this 
provider is not a network provider with the Plan. The Plan also says that they have also determined that these 
services are not urgent or emergent, nor were they approved in advance. 
 
 
 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 outpatient hospital clinic visit, and laboratory 
services provided on January 5, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for the acute inpatient hospital care associated with an 
elective total hip replacement surgery. 
 
You asked the Plan to pre-approve for acute inpatient hospital care. You say that total hip replacement surgery 
is normally done inpatient. The Plan denied your request. The Plan says the procedure is currently approved as 
an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will 
require a greater than 2 midnight stay. 
 
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 pre-approve for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the inpatient admission is not needed. The hip replacement surgery 
may be safely performed with a 48-hour observational stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve for the acute inpatient hospital care associated with an elective total hip 
replacement surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87496, 87529, 87640) provided September 28, 
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 documents do not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87496, 87529, & 87640 are not supported in the medical record. Specifically codes 
87496 and 87529 are not supported in the procedure report. Code 87640 is included in 87641 and is not 
separately payable. 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 (87496, 87529, 
87640) provided September 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound performed on February 1, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound performed on February 1, 2022. You say that you 
were billed the full allowable amount and would like this reconsidered. The Plan denied your request. The Plan 
says you must pay a $96.67 copayment for an ultrasound performed on February 1, 2022. 
 
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 $110 
copayment for an ultrasound.  
 
You have been asked to pay a $96.67 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan allowance for this service 
was only $96.67.  Since the Plans allowance is less than the contracted copayment, you are being asked to pay 
the lesser amount. 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 ultrasound performed on 
February 1, 2022.