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 enrollee needs IRF care to help them get ready to 
go home in a safe condition. The Plan denied your request. The Plan says the criteria for admission to the acute 
inpatient rehabilitation setting have not been met. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you are not pleased with the 
provider the Plan has recommended. The Plan denied your request. The Plan says there is an in-network 
provider that can perform the services you need. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that fact joint injections are medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injections do not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that in this case the 
enrollee has radiculopathy. The review has determined that the enrollee does not meet the coverage criteria 
detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
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 would benefit from the highest level of 
rehabilitation to regain his maximum function. The Plan denied your request. The Plan says the medical 
necessity for admission to an acute inpatient rehabilitation facility has not been met. 
 
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 clinical documentation shows that the enrollee has functional impairments 
however there are no complex functional deficits listed, thus they would not be expected to require intense 
therapy or interdisciplinary rehabilitation management in an IRF setting. Additionally, there are no active 
medical comorbidities specified and the enrollee would not be expected to require continued inpatient 
hospitalization in an IRF for close medical monitoring. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional miles for routine transportation. 
 
You asked the Plan to pre-approve additional miles. You say that this is the closest network doctor, and you 
feel this trip should be covered. The Plan denied your request. The Plan says the requested trip exceeds the 
mileage limit for coverage. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 75 miles of driving 
distance. 
 We looked at your request, the records in the case file, and the rules. In this case the requested trip exceeds 75 
miles. Based on this information, we decided that the Plans rules for coverage of routine transportation have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the additional miles for routine 
transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 6, 2022 to 
January 7, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the 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 secondary diagnosis code G93.41. 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 submitted records do not support the billing of secondary diagnosis code G93.41. 
Our physician reviewer found the enrollee presented to the emergency department with weakness, dizziness, 
and slurred speech. The computed tomography (CT) scan of the brain did not show any acute process. The 
history and physical noted she was alert and cooperative with normal speech. Magnetic resonance imaging 
(MRI) diagnosed an acute cerebrovascular accident. Per the literature, clinical signs and symptoms of 
metabolic encephalopathies consist of a generalized depression of cerebral function, including consciousness. 
In this case there was no clinical or laboratory indicators for metabolic encepahlopathy. The review has 
determined that the records do not support the billing of secondary diagnosis code G93.41.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 6, 2022 to January 7, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, 87150 and 87801 
billed for date of service October 20, 2021. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87653, 87150 and 87801. You say that these 
services were necessary and were reported correctly. The Plan denied your request. The Plan says these 
services are not supported 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. 
 
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 87481, 87640, 87653, 87150 and 87801. 
Our reviewer says that these codes are not supported in the medical records provided. Our reviewer found each 
of the services at issue were billed with modifier 91 to indicate a repeat clinical diagnostic laboratory test. In 
this case, this modifier is not supported as there is no second test for any of these procedures to support a repeat 
test. In addition, reporting codes 87481, 87640 and 87653 as separate from 87150 and 87801 is not supported, as these services are included in codes 87150 and 87801 and were performed with the same methodology. The 
record also does not include documentation of culture typing by nucleic acid probe, and therefore this service 
cannot be verified. This review has determined that the services at issue were not reported in accordance with 
Medicare guidelines. 
 
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 87481, 87640, 87653, 87150 and 87801 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, 87150 and 
87801 billed for date of service October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an abdominal ultrasound provided on July 
21, 2021, an abdominal magnetic resonance imaging (MRI) scan and injection provided on July 31, 2021, and 
hand x-rays provided on September 24, 2021. 
 
You asked the Plan to waive the cost share for the radiologic services and an injection. You say that you are 
disputing the amount assessed by the Plan. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that there is a $15 
copayment for each Medicare-covered standard x-ray service, and 10% coinsurance for each Medicare-covered 
medical supply after your $500 plan deductible. 
 
The record shows your deductible was not met prior to receiving services on July 21, 2021. The cost sharing 
amount for an ultrasound provided on July 21, 2021, and MRI provided on July 31, 2021, was applied to your 
deductible. You have been asked to pay 10% coinsurance for medical supplies received on July 31, 2021. You 
have also been asked to pay a $15 copayment for each x-ray received on September 24, 2021. 
 
DATE OF 
SERVICE 
 
SERVICE 
ALLOWED 
AMOUNT 
 
DEDUCTIBLE 
 
COST SHARE 
July 21, 2021 76775 $67.14 $67.14  
CLAIM TOTAL   $67.14  
July 31, 2021 74183 $438.01 $432.86 $5.15 
July 31, 2021 A9585 $33.00  $3.30 
CLAIM TOTAL    $441.31 
September 24, 2021 73130-LT $41.99  $15.00 
September 24, 2021 73130-RT $41.99  $15.00 
CLAIM TOTAL    $30.00 
TOTAL    $538.45 
 
These items/services fall within the outpatient diagnostic 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 cost share for an abdominal ultrasound provided on July 21, 2021, an abdominal magnetic 
resonance imaging (MRI) scan and injection provided on July 31, 2021, and hand x-rays provided on 
September 24, 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 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 the enrollee has a past medical history of diabetes and a resolved COVID infection 
and is living at home with weakness. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are weak and need rehab to get your strength 
back before returning home. The Plan denied your request. The Plan says that the request is not medically 
necessary. 
 
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 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have documented skilled nursing needs, though monitoring of your 
blood pressure and renal function is reasonable. You have documented skilled therapy needs and functioning 
below your baseline. The Plan cited your status on November 14, 2022, as the basis for their denial, but no 
such records have been identified for review. As such, the Plan has failed to support its denial. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready to discharge to an acute 
rehabilitation facility to begin recovery. 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services 
and regular physician evaluation. Our reviewer also found that the enrollees care 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from July 1, 
2021, to July 17, 2021, at the Patient-Driven Payment Model (PDPM) rate code billed. 
 You asked the Plan to pay for SNF care at the original code billed. You say that these services were necessary 
and were reported correctly. The Plan denied your request. The Plan says the PDPM code submitted on this 
claim is not appropriate for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report SNF services with the appropriate PDPM code. 
 
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 SNF care at the original code billed. Our 
reviewer says that the Plan's denial of the original PDPM code is appropriate in this case. Our physician 
reviewer found the case file does not contain sufficient documentation by the physician to support a diagnosis 
of morbid obesity due to excess calories (E66.01). In addition, the case file does not contain sufficient 
documentation to support a physical/occupational therapy score of 10-23 or a nursing function score of 6-14. 
 
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 at the original code billed have not been met. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) services provided from July 1, 2021, to July 
17, 2021, at the Patient-Driven Payment Model (PDPM) rate code billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on May 5, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware you lost your dental 
coverage through your retiree plan. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental 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. 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the resin-based composite (D2392) provided on May 5, 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. The Plan denied your request. The Plan says the 
LTACH would add no additional 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 physician 
reviewer found that the enrollee was admitted to the acute care hospital following a fall in which he suffered a 
subdural hematoma. The record indicates that the enrollee has had a complicated hospital course, has ongoing 
acute medical issues, and still requires acute care services. The enrollee continues to receive acute care 
services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. The elements of 
the coverage rules are not satisfied. The requested service cannot be 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.