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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You previously hospitalized for an infection and experienced deconditioning and 
now you are at home with home health services and care giver assistance. Your medical condition is being 
managed on an outpatient basis. You do not require rehabilitation nursing for complex wound care, parenteral 
nutrition, tube feedings, tracheostomy management or bowel and bladder management. Your medical and 
rehabilitation needs do not require the intensive interdisciplinary approach provided on acute inpatient 
rehabilitation. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a 
week, or 15 hours over seven consecutive days. You are independent with bed mobility and require minimal 
assistance with ambulation with a walker. You require supervision with transfers and activities of daily living. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services (97110, 97140, G0283, and 
97010) provided on October 26, 2020. 
 
You asked the Plan to pay for codes 97110, 97140, G0283, and 97010. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 made 
multiple attempts to obtain the bill with no response. As the secondary insurer, the Plan cannot be held 
responsible for codes 97110, 97140, G0283, and 97010 until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the physical therapy services (97110, 
97140, G0283, and 97010) provided on October 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dry needling therapy services. 
 
You asked the Plan to pre-approve dry needling therapy services. You say that this therapy is medically 
necessary for your condition. The Plan denied your request. The Plan says this acupuncture care is not covered 
by Medicare for your condition. 
 
The Plan must follow Medicare rules. The rules say that all types of acupuncture including dry needling for any 
condition other than CLBP are non-covered by Medicare 
 
 We looked at the file and Medicare rules. In this case, the requested dry needling acupuncture services is being 
requested not for CLBP but for elbow pain. Based on this information, we decided that the rules for coverage 
of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-
approve dry needling therapy services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires SNF care prior to returning 
home. The Plan denied your request. The Plan says the enrollee is functioning at a community level and has no 
daily skilled needs. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
SNF care is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (83789-59) provided on February 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says modifier -59 is not 
supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 use 
of modifier -59 is not supported by the records provided. Our physician reviewer found that modifier -59 is 
used to identify procedures/services, other than E/M services, that are not normally reported together, but are 
appropriate under the circumstances. Documentation must support a different session, different procedure or 
surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of 
injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. 
This is not documented in the case file. 
 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 the services (83789-59) provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 99153 provided on March 11, 
2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 find that CPT code 99153 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 3. This code was billed with place of service 21 (inpatient hospital). This 
code may not be paid if furnished to a hospital inpatients or patients in a hospital outpatient department. Based 
on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99153 provided on 
March 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the emergency department visit for 
evaluation and management provided on March 8, 2022. 
 
You asked the Plan to reduce the copayment for the emergency department services. You say that you went to 
the same facility for similar things like this previously and was never billed for an ER visit at an urgent care. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for emergency room services. Emergency department services 
fall within the Emergency Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for 
the emergency department visit for evaluation and management provided on March 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 currently unstable for transfer and requires additional acute 
care services that can be administered safely at the current facility until more stable and appropriate for a lower 
level of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary at this time as the patient is not 
yet stable for transfer and as it would not be clinically advantageous. 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the extremity study, a scan of extremity 
veins with responses to compression and other maneuvers provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for the extremity study. You say that there was no radiology scans 
done on the date of service. You say that the provider is committing fraud or bill padding. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $125 
copayment for radiological diagnostic services.  
 
 
 
 
 
 
 You have been asked to pay a $125 copayment for an extremity study. The extremity study 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 copayment for the extremity study, a scan of extremity veins with responses to compression and 
other maneuvers provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on April 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for oxygen equipment. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 oxygen equipment provided on April 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan from skull base to mid-thigh. 
 
You asked the Plan to pre-approve a PET/CT scan from skull base to mid-thigh. 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. Medicare rules say that positron emission tomography (FDG) for 
oncologic conditions are covered under certain circumstances.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PET/CT scan from skull base to mid-thigh have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) scan from skull base to mid-thigh.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for your inpatient hospital stay provided from 
March 28, 2022, to March 30, 2022. 
 
You asked the Plan to waive the copayment for your inpatient hospital stay. You say that you paid $350 up 
front, and you want to know what the extra $350 you owe was for. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 $350 
copayment each day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a total of $700 for an inpatient hospital stay ($350 per day x 2 days = $700 
copayment). There is no charge for the day of discharge. Inpatient hospital services falls within the Inpatient 
Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for your inpatient hospital stay 
provided from March 28, 2022, to March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are out-of-network with the Plan, so no 
precertification was obtained prior to the visit. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider with the Plan. The Plan also says that they did not authorize any 
services for the rendering provider or the facility. 
 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 laboratory services provided on March 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stivarga. 
 
You asked the Plan to pre-approve Stivarga. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Stivarga.  
 
Benefits for Stivarga may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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, we have confirmed that codes 
81413 and 81414 are column II codes to column I code 81439 with a modifier indicator of 0. The column II 
codes are therefore not payable.  
 
The rules also explicitly say that screening tests are not covered. The remaining codes at issue were requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on October 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97162, 95992) provided on 
February 16, 2022. 
 You asked the Plan to pay for physical therapy services. You say that the diagnosis codes used on this claim are 
valid and accurate. The Plan denied your request. The Plan says the diagnosis codes on this claim were not 
billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that each unique ICD-10-CM diagnosis code may be reported only once for an encounter. 
This applies to bilateral conditions when there are no distinct codes identifying laterality or two different 
conditions classified to the same ICD-10-CM diagnosis code. Codes for unspecified side should rarely be 
used, such as when the documentation in the record is insufficient to determine the affected side and it is not 
possible to obtain clarification. 
 
This claim was billed with ICD-10 codes H81.11 (benign paroxysmal vertigo, right ear) and H81.10 (benign 
paroxysmal vertigo, unspecified ear). These codes cannot be billed together, as the unspecified code may only 
be used when there is no documentation to support which side is affected and it is not possible to obtain 
clarification. If the right side is affected, then an unspecified side is not supported. In addition, if the 
unspecified side is intended as the left ear, then neither code is supported and the code for the bilateral 
diagnosis should be used. Based on this information, we decided that Medicare billing rules have not been met. 
Therefore, we decided that the Plan does not have to pay for physical therapy services (97162, 95992) provided 
on February 16, 2022.