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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that every day that the enrollee's rehabilitation is delayed 
the more probable they will not recuperate. The Plan denied your request. The Plan says the Medicare 
guidelines for IRF admission were not met and the enrollee can receive the services they need at a skilled 
nursing facility. 
 
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 clinical documentation shows that the enrollee has complex functional 
impairments (hip fracture is IRF compliant). However, evaluating therapist documentation recommends less 
intensive rehabilitation and the enrollee's prior level of function required assistance with self-care tasks and 
activities of daily living thus the enrollee would not be expected to tolerate intense therapy (15 hours of therapy 
per week).  
 
It is also documented that the enrollee has dementia and was not able to recall safety precautions or carryover 
information from prior therapy sessions thus the enrollee would not be expected to significantly benefit from an 
intensive therapy program. Additionally, there are no specified active medical comorbidities thus 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. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the routine eyewear (V2100, V2750, V2020, S9999) provided on May 
4, 2022. 
 
You asked the Plan to pay for the routine eyewear. You say that you had issues with your first pair of glasses. 
The Plan denied your request. The Plan says that you have already used your eyewear allowance. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
Though the Plan offers a vision benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your routine eyewear benefit was previously exhausted. 
Therefore, we decided that the Plan has to pay for the routine eyewear (V2100, V2750, V2020, S9999) 
provided on May 4, 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: 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 are appealing this denial. The Plan denied your 
request. The Plan says the denial of IRF care is correct. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation services so 
you can return safely to your prior level of function and/or maximum potential. The Plan denied your request. 
The Plan says services you need can be provided safely in other settings, for example, a skilled nursing facility, 
home with home health services or home with outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of tissue expander(s) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve insertion of tissue expander(s) to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
insertion of tissue expander(s) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76937, 36556, and 36620 billed for date of 
service November 17, 2021. 
 
You asked the Plan to pay for the billed services. You say that the reports support the procedures billed. The 
Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. The CPT Code Manual definition of code 36620 is arterial 
catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous. We 
find that CPT codes 36556 and 36620 is not supported in the medical record. Specifically, the records show 
that catheter placement services were provided on November 18, 2021. 
 
We find that CPT code 76937 has a PC/TC of 1. This code was not billed with a modifier suitable for payment. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 76937, 36556, and 36620 
billed for date of service November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot stay at the facility without their 
insulin. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met 
and the enrollee can receive the services they need at a skilled nursing facility. 
 
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 clinical documentation shows that the enrollee has functional impairments 
but there are no complex functional deficits specified or active medical comorbidities that would require 
inpatient hospitalization noted thus 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. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you are a fall risk and need to equipment 
to get around. You say that you are too weak to work a manual wheelchair or walker. The Plan denied your 
request. The Plan says there has been no evaluation of the enrollee's ability to operate a scooter/power operated 
vehicle without having an accident. The Plan say that there is no evaluation of the enrollee's ability to safely 
transfer to and from a power operated vehicle.  
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered for specific 
medical indications.  
 
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 a power wheelchair. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found there is insufficient 
documentation provided regarding the patients level of mobility and function as well as physical examination 
findings. He is noted to have 2/5 motor strength in the lower extremities, but his level of mobility is unclear. 
There is insufficient documentation regarding his upper extremity motor strength and why he cannot use a 
manual wheelchair for mobility. There is also no documentation indicating that the patient can safely operate 
the requested group 2 power wheelchair. The requested group 2 power 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 a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88112-26-59 billed for date of service 
January 19, 2022. 
 
You asked the Plan to pay for procedure code 88112-26-59. You say that this service was necessary and should 
be paid. 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 April 8, 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 procedure code 88112-26-59 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88112-26-59 billed for date of 
service January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing of 22 or more drug classes (G0483) 
provided June 15, 2022. 
 
You asked the Plan to pay for the drug testing. You say that the toxicology drug screen provides important 
information for physicians to properly diagnose and treat patients based on genetic testing. The Plan denied 
your request. The Plan says under Medicare rules, the requested number of definitive urine drug classes are not 
medically necessary. 
 
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 drug testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of chronic pain and is being prescribed Oxycodone and Gabapentin. 
Definitive drug testing of 22 or more drug classes was performed and is being requested for coverage. 
However, the provided documentation did not clearly show an abnormal or unexpected urine drug screening 
test prior to this definitive testing completion or any report of signs of drug abuse/misuse that would justify a 
comprehensive and definitive drug follow-up test, particularly as the panel includes irrelevant drug classes to 
this case. Therefore, this request for the definitive drug testing will be considered not medically necessary 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive drug testing of 22 or more drug classes (G0483) provided June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a patient management visit provided on 
May 31, 2022. 
 
You asked the Plan to waive the deductible for a patient management visit. You say that you don't understand 
why the plan paid so little. The Plan denied your request. The Plan says this cost sharing was charged 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 $225 
deductible for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay the 
allowed amount of $113.05 was applied to the $225 deductible, which was not met yet. 
 
You have been asked to pay a $113.05 deductible for a patient management visit. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies 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 deductible for a patient management visit provided on May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99201 billed for date of service May 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that there is sufficient documentation to support the 
services provided. The Plan denied your request. The Plan says that the service is included in the payment for 
another 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 99291 was billed along with CPT code 93010. There are no code edits for this code 
pair. Code 93010 does not have a global surgery period. Based on this information, we decided that Medicare 
rules for coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99201 billed for date of service May 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 17, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing, which is not separately payable. We find that the records do not show that definitive 
drug testing code G0480 was ordered. While a physician order is not required to be signed, the physician must 
clearly document, in the medical record, his or her intent that the test be performed. This has not been shown in 
the records.  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 the lab testing services provided on May 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 16, 2021 to 
October 24, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
service was medically necessary. The Plan denied your request. The Plan says the records do not support the 
billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis codes A41.9 and R65.20. 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that the records do not support the billed diagnosis codes. Our physician reviewer found 
there was no clinical or laboratory evidence of sepsis. Diagnosis codes A41.9 (sepsis unspecified organism) 
and R65.20 (severe sepsis without septic shock) are not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 16, 2021 to October 24, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this enrollee does not meet medical necessity and criteria for the requested 
acute inpatient rehabilitation admission. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF admission and services.