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

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission is medically necessary. 
The Plan denied your request. The Plan says based on Medicare guidelines, the long term acute care hospital 
services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with a hemorrhagic stroke with 
acute respiratory failure requiring mechanical ventilation support and complicated by pneumonia antibiotics. 
Trach and percutaneous endoscopic gastrostomy were placed. Recent notes describe the enrollee as now 
tolerating trach collar trials during the day, with stable vitals, tolerating tube feeds, but still with poor 
neurologic status and unable to communicate or follow basic commands.  
 
 The enrollee appears to be more stable and improving and should only require short-term additional acute care 
services that can safely be administered at the current facility until more stable and appropriate for a lower 
level of care. The enrollee does not require services at the LTACH that are not available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has had limited mobility for the past 
year and requires maximum assistance due to on-going falls. The enrollee is at considerable risk for fall, injury, 
and hospitalization if he does not receive intervention. The Plan denied your request. The Plan says the IRF 
care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled 
nursing facility (SNF). 
 
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. While the 
enrollee may benefit from additional multiple therapies, including physical and occupational therapy, the 
documentation does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 code 70450 billed for date of service May 11, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for IRF 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation doesnt support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain his functional status.  You can receive further 
services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 did not provide a specific argument for 
coverage. The Plan denied your request. The Plan says you do not meet criteria for approval of 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 you were admitted to an acute hospital on September 21, 2022, with a left hip 
fracture after a fall.  You had a left hip hemiarthroplasty with no complications.  You are medically stable at this time and do not require physical medicine physician supervision three times a week.  You have no acute 
rehab nursing needs. At your current level of function, you do not need intensive therapies.  Although you may 
benefit from continued physical and occupational therapy, your rehab needs can be safely provided in a lower 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service March 31, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services are supported in the 
medical record. The Plan denied your request. The Plan says they have agreed to pay for the drug testing 
services; however, code 83789 is for specimen validity testing which is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on February 2, 
2022, and gingival irrigation (D4921) provided on February 24, 2022. 
 
You asked the Plan to pay for an evaluation and gingival irrigation. You say that you needed these services 
sooner than expected. The Plan denied your request. The Plan says a limited oral evaluation (D0140) and 
gingival irrigation (D4921) are not covered by your dental benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental 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 limited 
oral evaluation (D0140) provided on February 2, 2022, and gingival irrigation (D4921) provided on February 
24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (code 97026) provided from January 25, 
2022, to March 24, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that you have provided medical records to support 
payment of these services. The Plan denied your request. The Plan says infrared therapy is not covered. 
 The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not covered for any 
indication.  The services represented by billed code 97026 are for infrared therapy. Therefore, we decided that 
the Plan does not have to pay for infrared therapy (code 97026) provided from January 25, 2022, to March 24, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the evidence clearly supports the 
procedure for chronic low back pain. The Plan denied your request. The Plan says the clinical effectiveness has 
not been demonstrated. 
 
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 requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. Therefore, the request 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
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 need IRF care so you can safely return to your 
prior level of function and maximum potential. The Plan denied your request. The Plan says IRF care 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 you were admitted to the hospital on September 14, 2022, with ankle pain. Your medical history does not meet criteria for IRF admission.  You are medically stable and do not need physical 
medicine physician supervision three times per week. You have no acute rehab nursing needs.  You do not 
need intensive therapies consisting of at least 3 hours of therapy per day, for at least 5 days a week.  While you 
may benefit from continued physical and occupational therapy, your rehab needs can be met at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for percutaneous arterial transluminal mechanical thrombectomy 
and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic 
guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s) provided to the 
enrollee on November 13, 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 it is not appropriate to report a right (RT) diagnosis code when the procedure modifier (LT) on 
the claim line does not match the diagnosis code. 
 
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 61645 is "Percutaneous arterial transluminal mechanical 
thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, 
fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s)." 
 
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 the diagnosis reported for this 
procedure is R53.1 weakness and H53.461 Homonymous bilateral field defects, right side. In this case, an 
intervention was performed on left side per procedure report, and in this case a diagnosis to support this 
procedure should be reported. Therefore, the diagnosis reported for procedure performed cannot be verified. 
 
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 percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, 
intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and 
intraprocedural pharmacological thrombolytic injection(s) provided to the enrollee on November 13, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on January 8, 
2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the enrollee should not 
be responsible to pay this. The Plan denied your request. The Plan says that the cost share was applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for Medicare-covered emergency room visits.  
 
The enrollee has been asked to pay $70.36 for emergency room services. Emergency room services falls within 
the Emergency Care benefit category. The enrollees contract with the Plan clearly says that he must pay a $90 
copayment for Medicare-covered emergency room visits. However, he has only been asked to pay $70.36, 
which is less than the $90 copayment amount. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an emergency room visit on January 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI performed on May 5, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you are experiencing financial hardship 
and cannot pay this. The Plan denied your request. The Plan says that the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 
copayment for each Medicare-covered diagnostic radiology service other than CT scans.  
 
You have been asked to pay $216.70 for an MRI. An MRI falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. Your contract with the Plan clearly says that you must pay 
a $375 copayment for an MRI. However, you have only been asked to pay $216.70, which is less than the $375 
copayment 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 MRI provided on May 5, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 49507-62 and 55520-62-XS billed for date 
of service April 4, 2021. 
 
You asked the Plan to pay for procedure codes 49507-62 and 55520-62-XS. You say that these codes should be 
paid. The Plan denied your request. The Plan says the documentation does 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 49504-62 is Repair initial inguinal hernia, age 5 years or 
older; incarcerated or strangulated; with modifier  62 (Two surgeons).  The CPT Code Manual definition of 
code 55520-62-XS is Excision of lesion of spermatic cord (separate procedure); with modifier 62 (Two 
surgeons) and XS (Separate structure). 
 
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 procedure codes 49507-62 and 55520-62-XS. Our reviewer says that the medical records do not support the billing of procedure codes 49507-62 and 55520-62-XS. Our 
reviewer found for code 49507-62, the modifier cannot be verified. The operative report documents an 
assistant, however documentation does not include what procedures were performed by the assistant to support 
modifier 62. In relation to code 55520-62-XS, the -62 modifier cannot be verified. The operative report 
documents an assistant, however documentation does not include what procedures were performed by the 
assistant to support modifier 62.  Modifier XS is supported by the operative report as a separate procedure from 
the hernia repair. The operative report describes a hernia repair with mesh, and then a lipoma was found on 
spermatic cord and excised.   
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 49507-62 and 55520-62-XS have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 49507-62 and 55520-62-XS billed for date of 
service April 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI (magnetic resonance imaging) of spinal canal 
and contents, cervical without contrast (72141). 
 
You asked the Plan to pre-approve an MRI of spinal canal and contents, cervical without contrast. You say that 
the service is medically necessary. The Plan denied your request. The Plan says the requested service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of spinal canal and contents, 
cervical without contrast. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found your pain is documented as starting September 19, 2022 (less than 3 weeks ago). You have not received 
at least six weeks of medications to treat your condition. You were also referred to an orthopedic specialist for 
evaluation. In addition, you have no documentation of receiving physical therapy or home exercises program 
for at least six weeks. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of spinal canal and contents, cervical without contrast 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI (magnetic 
resonance imaging) of spinal canal and contents, cervical without contrast (72141).