Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0268 billed for date of service January 31, 
2022. 
 
You asked the Plan to pay for procedure code G0268. You say that supporting medical records are enclosed for 
review and the claim should be reimbursed accordingly. The Plan denied your request. The Plan says there are 
no modifiers allowed with this code pair. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code G0268 
is a column II code to column I code 92524 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code G0268 billed for date of service January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on April 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for oxygen equipment. You say that you were unaware that the provider is out-of-
network. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 21, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient stay following the Zephyr valve placement. 
 
You asked the Plan to pre-approve the inpatient stay. You say that you would like approval for the inpatient 
stay based on the Food and Drug Administration (FDA) approved labelling for the product. The Plan denied 
your request. The Plan says that an inpatient stay is not medically or clinically necessary. The Plan also says 
that the services can be provided as an observation level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the inpatient stay. Our reviewer says 
that the documentation supports that the criteria for an inpatient stay are met in this case. Our physician 
reviewer found the record indicates that the enrollee is scheduled for an approved Zephyr valve placement. The 
FDA label states that patients should remain in-hospital for the first 3 nights after the procedure. Our reviewer 
found that the FDA saying the enrollee should remain in-hospital is a mandatory, not permissive construct. The 
elements of the coverage criteria are satisfied. Our physician reviewer also found that the requested service 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 inpatient stay have been met. Therefore, we decided that the Plan has to pre-
approve an inpatient stay following the Zephyr valve placement.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 2, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed based 
on the medical records. 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 January 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines 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 enrollee was admitted for osteomyelitis and transtibial amputation of the 
foot. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has 
a need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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 the IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
March 9, 2022, to March 16, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehab. You say that the care was approved and 
should be covered. 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 $300 per 
day for days 1-5 and $0 per day for additional days for each inpatient stay.  
 
The file shows that you were in the rehab facility from March 9, 2022, to March 16, 2022. Therefore, you have 
been asked to pay $300 per day for days 1-5 of inpatient rehab. The total for your stay is $1,500 ($300 
copayment x 5 days = $1,500). The inpatient rehab 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 inpatient rehabilitation care 
provided from March 9, 2022, to March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of inpatient 
rehabilitation admission. The Plan denied your request. The Plan says admission was denied as not meeting 
acute inpatient rehabilitation, is not medically necessary, and a lower level of care might be appropriate. Skilled 
nursing facility level of care was offered. 
 
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 has a past medical history of congestive heart failure, diabetes, end 
stage renal disease and sacral pressure ulcer and is living at home after discharge from skilled nursing facility. 
There is ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
While the enrollee has a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 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 the IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis and addition to lower extremity 
orthosis provided on December 20, 2021. 
 
You asked the Plan to pay for the ankle foot orthosis and addition to lower extremity orthosis. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the items rendered are not 
supported by the documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that a valid proof of delivery or a delivery ticket was not submitted to indicate the specific supplies 
rendered. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis and addition to 
lower extremity orthosis provided on December 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy provided on 
November 24, 2021. 
 
You asked the Plan to waive the copayment for occupational therapy. You say that you cannot the copayment 
for each visit. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $35 
copayment for each Medicare covered occupational therapy visit.  
 
You have been asked to pay $35 copayment for occupational therapy. Occupational therapy falls within the 
Outpatient Rehabilitation Services 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 
occupational therapy provided on November 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 11, 2021, to January 5, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are missing required information. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Review of the file shows that a RAP was not 
submitted within 5 calendar days from the start of care date. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the RAP was 
not submitted until January 5, 2022. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from December 11, 2021, to January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Orcam reader device (E1399). 
 
You asked the Plan to pre-approve an Orcam reader device. You say that the requested device would improve 
your quality of life. The Plan denied your request. The Plan says the requested device is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an Orcam reader device (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the intensive rehabilitation program is where the 
enrollee can get back to prior functioning status like before the stroke. The Plan denied your request. The Plan 
says based on Medicare guidelines the inpatient rehabilitation facility 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 enrollee was admitted for dizziness and hypotension. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 the IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient acute rehabilitation is the only chance the 
enrollee may have at approval for his transplant, enabling him to return to his prior level of function or higher. 
The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has a past medical history of end stage renal disease, coronary artery 
disease, diabetes, spinal infusion, and is living at home with progressive weakness.  Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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 the IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says based on Medicare guidelines the inpatient rehabilitation facility 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 enrollee was admitted for a pelvic fracture after a fall and was transferred to 
skilled nursing on August 13, 2022. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 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 the IRF admission and services.
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 enrollee needs LTACH care. The 
Plan denied your request. The Plan says the documentation fails to indicate that the enrollee is medically stable 
for discharge from an acute inpatient setting. 
 
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 that all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. 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 long term acute care hospital (LTACH) services.