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

 
We decided that the Plan has to pay for the inpatient admission provided from April 8, 2022, to April 14, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
that the inpatient admission was not medically necessary. 
 
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 the record shows that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department 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 inpatient admission provided from April 8, 2022, to April 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sacroiliac joint radiofrequency ablation provided to the 
enrollee on August 23, 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 radiofrequency ablation used for sacro-iliac joint pain is considered not medically 
necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered an experimental/investigational procedure because of the wide variation in 
efficacy as reported in the literature. Therefore, the procedure was considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for sacroiliac joint radiofrequency ablation provided to the enrollee on August 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says a fall risk was not identified at the time of evaluation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found that there is no evidence supporting a response to skilled therapy. There is no 
evidence that continued input from a skilled therapist will improve outcomes or alter your medical status. You 
are able to manage lymphedema with a home program. The continued therapy is not consistent with the 
enrollee's response or current condition. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve outpatient physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided 
to the enrollee on November 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 records do not support the services 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 99153 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that per the billing indicators, procedure code 99153 has an indicator of 3 which represents billing for technical component (TC). The 
medical records do not support the use of this procedure code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on November 4, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of 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. You 
are medically stable and do not need physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. There are no acute nursing needs identified or documented. At the current functional level, you do 
not need therapy 3 hours a day, 5 days a week. You will not make a significant functional progress as you will 
not be able to tolerate intense therapies in an IRF. While you would benefit from physical and occupational 
therapy, your rehab needs can be safely provided in an alternate and low intensity setting. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard manual wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that you have almost fallen multiple times, which 
would result in a possible major injury. The Plan denied your request. The Plan says this equipment is for use 
outside of the home. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that 
the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the clinical documentation states that you are able to complete activities of daily living 
effectively with a walker inside the home. Thus, a manual wheelchair is not 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 the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a standard manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92004) and refraction (92015) 
provided on April 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a medical eye examination and refraction. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services were not approved of in advance 
and were not urgent or emergent. 
 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 a medical eye examination (92004) and refraction 
(92015) provided on April 1, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would not get necessary treatment at a 
lower level of care. The Plan denied your request. The Plan says an intensive rehabilitation program is not 
medically necessary. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44180 billed on September 9, 2021. 
 
You asked the Plan to pay for procedure code 44180. You say that the code was listed twice but you only 
entered it once. You say that the claim should be reviewed for payment of one code. The Plan denied your 
request. The Plan says there are no modifiers allowed with this code pair. 
 
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 44180 
is a column II code to column I code 47562 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 procedure code 44180 billed on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a product protection plan received on April 28, 2022. 
 
You asked the Plan to pay for a product protection plan. You say that you don't understand what the charge is 
for. The Plan denied your request. The Plan says this is not a covered benefit. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Though the Plan offers a vision benefit in excess of Medicare 
coverage, the requested items or services are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for a product protection plan received on April 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for an inpatient hospital stay from October 21, 
2021, to October 25, 2021. 
 
You asked the Plan waive the copayment for an inpatient hospital stay. You say that you should not be 
responsible for this amount. The Plan denied your request. The Plan says the cost share has been 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $100 per day for days 1 to 7, per admission, for Medicare-covered, in-network, inpatient hospital 
stays.  
 
You have been asked to pay $400 ($100/day x 4 days) for an inpatient hospital stay. An inpatient hospital stay 
falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the 
correct amount based on the contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have waive the copayment for an inpatient hospital stay from October 21, 2021, 
to October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-preferred brand of a continuous glucose monitor 
provided on November 28, 2021. 
 
You asked the Plan to pay for the provided monitor. You say that medical records were submitted. The Plan 
denied your request. The Plan says the expense does not meet the requirement of the enrollee's plan benefits. 
 The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred. 
 
The provided brand of supplies is not a Plan-preferred brand. The file does not include a medical exception as 
to why the enrollee is unable to use a Plan-preferred brand. The Plan did not pre-approve the items at issue. We 
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does 
not have to pay for the non-preferred brand of a continuous glucose monitor provided on November 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on May 3, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that this claim has been submitted 
several times and only partial payment has been made. The Plan denied your request. The Plan says no 
payment can be made on this claim as OCE edit 92 must be corrected.  
The Plan must follow Medicare rules. Medicare rules say that outpatient hospital claims must be processed 
through the I/OCE. The I/OCE will return claims to the provider when a device-intensive procedure is billed 
without a corresponding device code on the same claim.  
 
We looked at the file and Medicare rules. Code 19281 is a device-intensive procedure, and no device code was 
reported on the claim. Based on this information, we decided that Medicare rules for coverage of the outpatient 
hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient 
hospital services provided on May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 43254 and 43251 billed for date of service 
January 27, 2022. 
 You asked the Plan to pay for procedure codes 43254 and 43251. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 43254 and 43251 is bundled into 
payment for code 43270. 
 
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 43254 
is a column II code to column I code 43270. We have confirmed that code 43251 is a column II code to column 
I codes 43254 and 43270. 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 procedure codes 43254 and 43251 billed for date of service January 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a Tempus xT solid tumor panel provided on October 20, 2021. 
 
You asked the Plan to pay for a Tempus xT solid tumor panel. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that medical-necessity rules for 
payment have not been met because the testing panel at issue is not approved by the Food and Drug 
Administration (FDA). 
 
The Plan follows Medicare rules. The rules say that molecular pathology procedures may be eligible for 
coverage when the criteria listed in the Medicare rules section have been met. 
 
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 a Tempus xT solid tumor panel. Our 
reviewer says that the services at issue are medically reasonable and necessary in this case. Our physician 
reviewer found that the development of sophisticated genetic and molecular characterization of central nervous 
system (CNS) neoplasms has shown that histologically similar neoplasms can be characterized more accurately 
for prognosis and in some instances for response to different therapies. Molecular characterization of primary 
brain tumors/gliomas has had a substantial impact on stratification and eligibility in clinical trials for CNS 
neoplasms over the last 10 years and is increasingly becoming a common part of standard neuro-oncology 
management. The National Comprehensive Cancer Network (NCCN) guidelines recommends molecular 
profiling, such as with Tempus, to identify clinically relevant subtypes to encourage opportunities for clinical 
trial involvement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Tempus xT solid tumor panel have been met. Therefore, we decided that the 
Plan has to pay for a Tempus xT solid tumor panel provided on October 20, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798, and 87641 
billed for date of service November 10, 2021. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87653, 87798, and 87641. You say that this 
should be paid due to medical necessity. The Plan denied your request. The Plan says these billed codes are 
bundled into payment for other codes on the claim. 
 
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 87150 is a Column 2 code and in relation to 87500 and is bundled 
into payment for the Column 1 code. Codes 87481, 87653, 87798, and 87641 are also bundled with code 87150 
and 87801. 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 procedure codes 87150, 87481, 87653, 87798, and 87641 billed for date of service November 10, 2021.