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 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While he may benefit from 
additional multiple therapies, including physical and occupational therapy, the documentation does not reveal 
that he requires this therapy on an intensive IRF level. Therapy notes indicates the enrollee had fatigue with 
therapy. His therapy needs do not require an intensive program. 
 
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 office visit (99214) provided on December 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were not aware this provider was out-of-
network. The Plan denied your request. The Plan says prior authorization was not obtained for these services 
rendered by an OON 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 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 the office visit (99214) provided on December 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on IRF 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows that you have multiple active two or more diseases or medical 
conditions and hospital complications and would benefit from close medical monitoring on an inpatient basis. 
The evaluating therapists state you have good rehabilitation potential, and the provider states you would benefit 
from intense therapy. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450-26-77) provided on January 1, 2022. 
 
You asked the Plan to pay for the CT scan services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is a duplicate of 
a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 16, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the CT scan services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head or brain (70450-26-77) provided on January 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit provided on March 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the medical 
necessity of the services. The Plan denied your request. The Plan says the services were not urgent, emergent, 
or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the outpatient clinic visit provided on March 23, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 82310, 82728, 83540, 83550, 
83970, and 84100 provided on January 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services coded 82310, 82728, 83540, 83550, 83970, and 84100 provided on January 10, 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. The Plan denied your request. The Plan says your needs are not 
complex enough to require coordinated team approach. 
 
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 physician reviewer found 
that you were hospitalized with generalized weakness and a pleural effusion, etiology not entirely clear. The 
record is inconsistent as occupational therapy found you more impaired with transfer than did physical therapy 
(PT). PT found you very near baseline with close to community ambulation status.  Your level of function is entirely consistent with a standard hospital stay and post-acute care needs. You have 
neither intensive nor complex rehabilitation needs. Your rehabilitation needs are routine and do not require 
frequent physiatry oversight. You do not require treatment by multiple therapies in an intensive rehabilitation 
therapy program. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found use is not FDA approved, supported by 
major drug compendia, or the medical literature. Standard is as a single agent. The service is not reasonable or 
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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit and electrocardiogram 
provided on October 29, 2021. 
 
You asked the Plan to pay for the emergency department visit and electrocardiogram. You say that you would 
like the plan to reconsider their 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 services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99285 and 93010 is not supported in the medical record. Specifically, the 
documentation provided shows that the enrollee was seen in the emergency department on October 28, 2021 
and not the billed date of service of October 29, 2021. This means that this date of service is not supported by 
the documentation. Based on this information, we decided that Medicare rules for coverage of the emergency 
department visit and electrocardiogram have not been met. Therefore, we decided that the Plan does not have to 
pay for the emergency department visit and electrocardiogram provided on October 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
February 26, 2021, to March 21, 2021, as billed with Health Insurance Prospective Payment System (HIPPS) 
rate code KDYE1. 
 You asked the Plan to pay for SNF care billed with HIPPS code KDYE1. You say that this care was medically 
necessary, and all services/conditions were reported correctly. The Plan denied your request. The Plan says 
acute kidney failure (N17.9) is not supported in the medical record. therefore, use of "K" for the first character 
of the HIPPS code is not supported. The care provided in this case is best reported with "P" as the first 
character. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report SNF services with the appropriate HIPPS code. 
 
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 SNF care billed with PDPM KDYE1. Our 
reviewer says that the Plan's denial is appropriate in this case. Our physician reviewer found that the medical 
records do not support the billing of acute kidney failure (N17.9) for the SNF care provided from February 26, 
2021, to March 21, 2021. The case file does not contain physician documentation of this diagnosis. The 
medical and therapy records do not support the use of the K digit for the HIPPS code in this case. 
 
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 billed with code KDYE1 have not been met. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) services provided from February 26, 2021, 
to March 21, 2021, as billed with Health Insurance Prospective Payment System (HIPPS) rate code KDYE1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 vaccines (0001A, 0002A) provided April 15, 
2021 and May 5, 2021 
 You asked the Plan to pay for the COVID-19 vaccines. You say that you have not been paid anything and the 
EOB explanation is vague. Please note this is a COVID vaccine which has been approved by the federal 
government. The Plan denied your request. The Plan says the services should be billed to and is covered by 
Original Medicare. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the COVID-19 
vaccines. The Plan follows the same rules.  
 
In this case, Medicare payment for COVID vaccinations administered during calendar years 2020 and 2021 to 
MA beneficiaries will be made through the Medicare FFS program. Therefore, we decided that the Plan does 
not have to pay for the COVID-19 vaccines (0001A, 0002A) provided April 15, 2021 and May 5, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient consultation billed with code 99252 for date of 
service, November 13, 2021. 
 
You asked the Plan to pay for code 99252. You say that this service was billed appropriately, and the code 
utilized is valid. The Plan denied your request. The Plan says this service was billed with a code that is not 
valid for Medicare purposes. Medicare may use another billing code for this service. 
 
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 99252 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99252 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of code 99252 have not been met. Therefore, we decided that the Plan does not have to pay for an 
inpatient consultation billed with code 99252 for date of service, November 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation.  
 
 
 
 
 
 We looked at the file and Medicare rules. The record shows that the claim was billed with primary diagnosis 
code, I46.8. This code has a code first note, which means it is a manifestation code and must be sequenced after 
an etiology code. 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 pay for the ambulance services provided on 
February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (CPT code L1851). 
 
You asked the Plan to pre-approve the knee orthosis. You say that the enrollee had been using an over-the-
counter type brace, which they feel helps with the sense of stability and pain. You state that you have 
recommended that the enrollee be set up for a knee stabilization unloader type brace so as to provide the 
enrollee with a sense of stability, strength and allow the enrollee to increase their ability to function and 
activities of daily living. The Plan denied your request. The Plan says your request is not medically necessary 
because the enrollee's records do not show they have had a recent injury or surgery of the knees or objective 
evidence of knee instability. 
 
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 knee orthosis. Our physician 
reviewer found the enrollee was reported to have been using an over-the-counter type brace for pain and 
stability. A uniloader brace was requested. However, this brace is not medically necessary or meet Medicare 
criteria because the provided records do not show they have had a recent injury or surgery of the knees or 
objective evidence of knee instability to justify bracing at this time. 
 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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the knee orthosis (CPT code L1851).
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 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. 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 the 
services are not medically necessary. Our physician reviewer found based on the evidence, you are unable to 
respond to daily skilled therapy with material gains within a predictable timeframe. No daily skilled nursing 
needs. Criteria for continued skilled services are 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 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 the assistant surgeon services provided during the total knee 
arthroplasty on November 24, 2021. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
assistant surgeon services provided during the total knee arthroplasty on November 24, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 tests rendered on March 24, 2022. 
 
You asked the Plan to pay for these services. You say that you provide at-home tests billed to the enrollee's 
primary insurance. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and these 
services are an OTC item. The Plan does not have a supplemental benefit for coverage of at-home COVID-19 
tests. Therefore, we decided that the Plan does not have to pay for the COVID-19 tests rendered on March 24, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on February 21, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you would like to 
appeal the cost share. 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 a $120 
copayment per stay for each emergency room visit for emergency room services.  
 
You have been asked to pay a $120 copayment per stay for each emergency room visit for emergency room 
services. Emergency room services falls within the emergency 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 emergency room services on February 21, 2022.