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 is being referred and recommended to 
IRF, to be assessed both medically and functionally in regard to premorbid functional capacity to determine a 
benefit from a rehabilitation level of care offered by mentioned facility. The Plan denied your request. The Plan 
says the enrollee does not have any acute medical issues and does not meet the requirements for inpatient 
rehabilitation admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the durable medical equipment provided on September 28, 2022. 
 
You asked the Plan to pay for the durable medical equipment. 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. 
 
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 contain a valid physician order and proof of delivery for the supplies provided in this case. The 
delivery ticket includes the tracking number, which links the delivery ticket to the proof of delivery with the 
same tracking number. Therefore, we decided that the Plan has to pay for the durable medical equipment 
provided on September 28, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the anti-reflective lenses, the 
photochromatic lenses, the ultraviolet filter, and the polycarbonate lenses provided on October 14, 2022. 
 You asked the Plan to waive the cost share for the anti-reflective lenses, the photochromatic lenses, the 
ultraviolet filter, and the polycarbonate lenses. You say that you should receive a refund of $227.80. 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 you must pay a $15 
copayment that applies to the UV filter, a $65 copayment for the anti-reflective lenses, and 80% coinsurance 
for the photochromatic lenses and the polycarbonate lenses.  
 
You have been asked to pay $37.50 which is less than the $65 copayment for the anti-reflective lenses. You 
have been asked to pay $88 which is 80% of the allowed amount for the photochromatic lenses. The allowed 
amount is $110. ($110 x 80% = $88). You have been asked to pay $7.50 which is less than the $15 copayment 
for the ultraviolet filter. You have been asked to pay $16 which is 80% of the allowed amount for the 
polycarbonate lenses. The allowed amount is $20. ($20 x 80% = $16).  
 
These items fall within the vision 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 cost share for the 
anti-reflective lenses, the photochromatic lenses, the ultraviolet filter, and the polycarbonate lenses provided on 
October 14, 2022.  
 
Please note, you were overcharged by $86 and the issue to forwarded to the Plans Provider Engagement team 
to assist with the refund process.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75736-26-XU, 76380-26-XU, and 75774-
26-XU provided on October 10, 2022. 
 
You asked the Plan to pay for procedure codes 75736-26-XU, 76380-26-XU, and 75774-26-XU. You say that 
the medical records support the use of modifier XU with codes 75736, 76380, and 75774. The Plan denied your request. The Plan says the medical records do not support the use of modifier XU with codes 75736, 76380, 
and 75774. 
 
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 75736-26-XU, 76380-26-XU, and 75774-26-XU are column II 
codes to column I code 37243; however, 75736-26-XU, 76380-26-XU, and 75774-26-XU were billed with a 
modifier.  
 
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 75736-26-XU, 76380-26-XU, and 75774-
26-XU. Our reviewer says that the medical records do not support the use of modifier XU with codes 75736, 
76380, and 75774. Our reviewer found the approved CPT code 37243 according to CMS policy includes all 
angiographic studies for road-mapping for embolization. There is no description of any of the angiographic 
selective studies to justify another code with XU as a modifier since these angiographic studies are part of the 
usual road-mapping for embolization. The CPT code 76380 for limited computed tomography (CT) at the 
conclusion of the embolization would also be considered a normal part of the embolization study 37243. 
 
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 75736-26-XU, 76380-26-XU, and 75774-26-XU have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 75736-26-XU, 76380-26-
XU, and 75774-26-XU provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 rendered on April 5, 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 documents do not support this level of care. 
 
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 99236 is "Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 records submitted did 
not support medical decision making of high complexity. 
 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 procedure code 99236 rendered on April 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Vertiflex spacer is considered experimental. More research is needed to show 
safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869).
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. The Plan denied your request. The Plan says the enrollee's records 
do not require an intensive and coordinated interdisciplinary approach to rehabilitation, services needed can be 
provided safely in other settings, a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your condition does 
not meet all of the requirements and you may review alternate settings if requested such as a skilled nursing 
facility, outpatient setting or home health care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bevacizumab and paclitaxel. 
 
You asked the Plan to pre-approve bevacizumab and paclitaxel. 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 bevacizumab and paclitaxel. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the combination of 
bevacizumab and paclitaxel with or without atezolizumab is not FDA approved for the treatment of 
recurrent/progressive adenocarcinoma of the lung. Use is not supported by major drug compendia or the 
medical literature. The combination is not listed in the NCCN Guidelines. The service is not reasonable or 
medically necessary or safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bevacizumab and paclitaxel have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bevacizumab and paclitaxel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
April 11, 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 documents do not support this level of care. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 provided records in this case 
do not document medical decision making of high complexity. The medical decision making of high complexity requires an extensive number of diagnoses or management options, an extensive amount and 
complexity of data reviewed and high risk of complication. The provided records in this case do not document 
an extensive number of diagnoses or management options. 
 
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 initial hospital care (procedure code 99223) rendered on April 11, 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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the IRF admission you requested is denied as 
not medically necessary and reasonable. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP equipment provided from 
February 2, 2022, to December 29, 2022. 
 
You asked the Plan to waive the coinsurance for the CPAP equipment. You say that you have not had to pay 
for this equipment in the past. 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 you must pay 20% 
coinsurance for Medicare-covered durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the CPAP equipment. These items/services fall within the 
durable medical equipment benefit category. 
 
 
 
 Date of Service Allowed Amount Coinsurance  
February 2, 2022 $24.18 $4.84 
March 29, 2022 $76.85 $15.37 
April 12, 2022 $6.12 $1.22 
April 29, 2022 $76.85 $15.37 
May 12, 2022 $6.12 $1.22 
June 12, 2022 $6.12 $1.22 
July 29, 2022 $76.85 $15.37 
August 29, 2022 $76.85 $15.37 
September 29, 2022 $76.85 $15.37 
December 29, 2022 $76.85 $15.37 
Total $100.72 
 
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 coinsurance for the continuous positive airway pressure (CPAP) equipment 
provided from February 2, 2022, to December 29, 2022.
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 requires extensive wound 
care, anesthesia, and physical rehabilitation. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, and the enrollee's needs can be met in the current hospital 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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial 
of an IRF admission as the enrollee meets the criteria for admission to an acute IRF. The Plan denied your 
request. The Plan says the IRF services 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. 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 IRF admission and services.