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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee should be transferred 
immediately to the LTACH for a more extended acute care hospitalization based on the complexity of their 
current medical condition. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care and does not require transfer to an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for LTACH 
services. 
 
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 appears to be improving and more stable and should only require short-
term additional acute care hospital services that can safely be provided at the current facility. Transfer to the 
LTACH would not be clinically advantageous at this time and completion of treatment at the current facility is 
recommended. 
 
 
 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on August 17, 2021, 
to August 23, 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. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
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 I21.A1. 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 use of diagnosis code I21.A1 is not supported by the records provided. Our physician reviewer found 
that the enrollee presented to the emergency department with hypoglycemia. She also complained of shortness 
of breath. She was treated for hypoglycemia and a decompensation of congestive heart failure. The 
documentation indicates the enrollee had an elevation of Troponins, but did not have any ischemic changes in 
the EKG or symptoms of chest pain. The documentation does not indicate that the diagnostic work-up and 
treatment ordered by the treating medical providers supported diagnosis code I21.A1 (Myocardial infarction 
type 2).  
 
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 the inpatient hospital services provided on August 17, 2021, to August 23, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the false tooth-shaped cap (D6242) on teeth #'s 20, 24, 
25, 30 and the tooth-shaped cap for bridge (D6750). 
 
You asked the Plan to pre-approve the false tooth-shaped cap (D6242) on teeth #'s 20, 24, 25, 30.. You say that 
the bridge is necessary because the enrollee's front teeth will be missing, and the enrollee will not be able to eat 
properly. The Plan denied your request. The Plan says the false tooth-shaped cap (D6242) does not meet 
criteria. The Plan denied authorization because the tooth-shaped cap for bridge (D6750) is not a covered 
service. 
 
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. The Plan covers the false 
tooth-shaped cap (D6242) on teeth #'s 20, 24, 25, 30 when the services are medically necessary and reasonable.  
 
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 false tooth-shaped cap (D6242) on 
teeth #'s 20, 24, 25, 30. Our reviewer says that this service is not medically necessary. Our physician reviewer 
found that in this case there are missing posterior teeth (#20 and 30). Fixed bridges may be covered to replace two adjacent mandibular anterior teeth when there are no missing posterior teeth in the arch.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the false tooth-shaped cap (D6242) on teeth #'s 20, 24, 25, 30 have not been 
met. The tooth-shaped cap for bridge (D6750) is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve the false tooth-shaped cap (D6242) on teeth #'s 20, 24, 25, 
30 and the tooth-shaped cap for bridge (D6750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4223 billed for date of service May 6, 2022 
to May 13, 2022. 
 
You asked the Plan to pay for procedure code A4223. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4223 has a Status Indicator of x on the Physician Fee Schedule. This means that 
procedure code A4223 is statutorily excluded. Based on this information, we decided that Medicare rules for coverage of procedure code A4223 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4223 billed for date of service May 6, 2022 to May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure code 64493, 64494) provided to 
the enrollee on June 8, 2022. 
 
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 services were billed incorrectly, as a modifier was needed. A corrected claim submission is 
required. 
 
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 the denied codes is: 
 
CPT 64493: 
 
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 
 
CPT 64494:  
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition 
to code for primary procedure) 
 
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 medical record does not 
include documentation of injection of paravertebral facet joint, either the first level or second level. Of note, the 
medical record describes an infusion for dental procedure. There are no other medical records found in the 
documentation submitted.   
 
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 injection services (procedure code 64493, 64494) provided to the enrollee on June 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 11721 provided on July 15, 2022. 
 
You asked the Plan to pay for procedure code 11721. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 11721 have been met. In this case, the file shows that procedure code 11721 was 
billed without a Q modifier and requires a diagnosis code from group 2 and a diagnosis code from group 3 of 
the LCA to be submitted on the claim. Medicare says if a situation arises where two or more diagnoses are 
required for a procedure code, the provider shall reference only one of the diagnoses from item 21 in item 24 E. 
The claim correctly references diagnosis pointer C in item 24 E for procedure code 11721. Therefore, we 
decided that the Plan has to pay for procedure code 11721 provided on July 15, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is nearing discharge and will require an 
IRF admission for the best outcome possible and limit readmission risk. The Plan denied your request. The 
Plan says the IRF services you are requesting do not meet the requirements for approval. 
 
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 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo, Palonosetron HCL, Leucovorin calcium, 
Oxaliplatin, and Fluorouracil. 
 
You asked the Plan to pre-approve Opdivo, Palonosetron HCL, Leucovorin calcium, Oxaliplatin, and 
Fluorouracil. 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 Opdivo, Palonosetron HCL, Leucovorin 
calcium, Oxaliplatin, and Fluorouracil. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee is without clear progression on recent positron emission tomography 
(PET) and only single site. If progression is noted, switching to another programmed cell death ligand 1 (PD-
L1) inhibitor would not be indicated.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo, Palonosetron HCL, Leucovorin calcium, Oxaliplatin, and Fluorouracil 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo, Palonosetron 
HCL, Leucovorin calcium, Oxaliplatin, and Fluorouracil.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on September 21, 
2021. 
 
You asked the Plan to waive the deductible for an office visit. You say that your provider said you would not 
be charged for this visit. 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. Your 
contract with the Plan says that there is an $800 deductible which applies to doctor and other health care 
provider services.  
 
The item or service you asked the Plan to waive the deductible for falls within the doctor and other health care 
provider services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is an $800 deductible which applies to doctor and other health care provider services. This cost 
sharing is a contractual obligation that had not been met at the time an office visit was received on September 
21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided 
on September 21, 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 you need inpatient rehabilitation to make a full 
recovery. The Plan denied your request. The Plan says your therapy needs can be safely fulfilled 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 you do not require treatment by multiple therapies.  You have a had a decline from 
your baseline level of function and may benefit from therapy, but you do not require the intensity of therapies 
provided on acute inpatient rehabilitation. 
 
 
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 20936 billed for date of service February 3, 
2022. 
 
You asked the Plan to pay for procedure code 20936. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 20936 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service February 3, 2022.
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 the enrollee meets criteria and continues to be 
recommended for an IRF admission in order to return home safely within a reasonable time frame. The Plan 
denied your request. The Plan says the IRF services you requested do not meet the requirements for approval. 
 
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 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81479) provided on February 9, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim needs to be submitted 
to the enrollee's primary insurer before secondary payment may be made. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the enrollee's primary insurer. As the secondary insurer, the Plan cannot be held responsible for 
laboratory services until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for laboratory services (81479) provided on February 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's family believes that the services are 
medically necessary so that the enrollee can return home. The Plan denied your request. The Plan says the 
clinical information provided shows that a lower level of care would meet the enrollee's medical needs. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 inpatient rehabilitation facility (IRF) admission and services.