Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the third level facet joint injection (64495) provided on 
March 25, 2022. 
 
You asked the Plan to pay for procedure code 64495. You say that the additional level was medically 
necessary. The Plan denied your request. The Plan says the additional level was not medically necessary. 
 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 pay for procedure code 64495. Our reviewer says 
that the additional level was not medically necessary. Our physician reviewer found there was no 
documentation of extraordinary circumstances to explain the need for a third level to be performed. The third 
level exceeds utilization criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64495 have not been met. Therefore, we decided that the Plan 
does not have to pay for the third level facet joint injection (64495) provided on March 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74220-26 billed for date of service August 
22, 2022. 
 
You asked the Plan to pay for procedure code 74220-26. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 74220-26 is bundled into payment for 
code 74230-26. 
 
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 
74220-26 is a column II code to column I code 74230-26 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 74220-26 billed for date of service August 22, 
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 services are necessary for the 
enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer. 
 
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 there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current acute care hospital until such time no acute services are required.  The 
enrollee can then be transferred or discharged to a lower level of care for any ongoing long term care needs. 
 
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: 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 show the need for 24-hour nursing, based on current needs shows a skilled nursing facility level of 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 enrollee does not require treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy program.  
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: Unfavorable

 
We decided that the Plan does not have to pay for the two foot inserts (L3020 x2) provided on July 6, 2022. 
 
You asked the Plan to pay for the two foot inserts. The Plan denied your request. The Plan says the 
documentation does not support the shoe is an integral part of the brace. The Plan also says the medical records 
state the insert was fitted into the enrollee's current shoes, and therefore, will not be reimbursed. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  Records show that the enrollee does not suffer from diabetic foot disease but does wear a leg brace. However, 
the records show that the foot inserts were fitted into the enrollees current shoes. Although orthotics may be 
appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's 
condition. Therefore, we decided that the Plan does not have to pay for the two foot inserts (L3020 x2) 
provided on July 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need an extension of one or two days so you 
can get things done for discharge in order to travel from here to back home, have a new hospital bed installed 
allowing for any last-minute changes so please extend time and expedite my appeal. The Plan denied your 
request. The Plan says based on the additional information available, you do not meet the criteria for 
continuation of care at a SNF facility.  
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on August 18, 
2021. 
 
You asked the Plan to pay for initial hospital care (99223). You say that the claim was submitted within the 
original filing limit and the claim should be processed for payment. The Plan denied your request. The Plan 
says the original claim denied for the incorrect POS being billed and the new claim was not filed timely. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for services furnished on or after January 
1, 2010, must be filed no later than one calendar year after the date of service. Medicare rules also say that 
providers must report services correctly.  
 
 
  The record shows that a new claim for the initial hospital care was not filed until October 31, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided the Plan does not have to pay for the initial hospital care (99223) provided on August 18, 2021
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve durable medical equipment (DME). 
 
You asked the Plan to pre-approve DME. You say that you feel services should be covered. The Plan denied 
your request. The Plan says that you are not eligible based on providers response to attestation form. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case we requested the Evidence of Coverage (EOC) to review the Plans 
SSBCI policy. The requested EOC was not provided. Thus, we are unable to verify that the Plans denial is 
correct. Therefore, we decided that the Plan has to pre-approve durable medical equipment (DME).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexium capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this drug is not covered by Medicare Part B. 
 
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 Nexium capsules.  
 
Benefits for self-administered drug 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you qualify for the SSBCI benefit. The 
Plan denied your request. The Plan says you do not meet criteria for the expanded benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 SSBCI benefits. Our reviewer says 
that the SSBCI benefits are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have stable chronic back pain, hypothyroidism, peripheral neuropathy related to diabetes II, 
hypertension, and anxiety. SSBCI benefits were requested. However, the provided documentation did not clearly show evidence of you having one or more qualifying co-morbid and medically complex condition or 
have a condition that was life threatening or significantly limiting the overall health or function of the patient. 
Your conditions appeared well controlled and stable with a new adjustment anxiety disorder that was not 
complex or severe according to the notes. You are not at a high risk for hospitalization. Therefore, this request 
for SSBCI benefits will be considered not medically necessary. 
 
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 SSBCI benefits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vitamin D assay testing (code 82306) provided on 
April 21, 2022. 
 
You asked the Plan to pay for the vitamin D assay testing. You say that the vitamin D assay testing was 
medically necessary. The Plan denied your request. The Plan says the vitamin D assay testing was not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say vitamin D testing may not be used for routine screening. 
 
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 vitamin D assay testing. Our reviewer 
says that the requested vitamin D assay testing is not medically necessary in this case. Our physician reviewer 
found that the enrollee is an 89-year-old with diagnoses that include hypothyroidism, unspecified, 
thrombocytopenia, unspecified, hypertension, mild cognitive impairment, allergic rhinitis, and depression. The 
documentation does not support that enrollee in this case has an indication for measurement of vitamin D levels 
per the Medicare LCD L34658: Vitamin D testing may not be used for routine screening. 
 
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 vitamin D assay testing have not been met. Therefore, we decided that the 
Plan does not have to pay for vitamin D assay testing (code 82306) provided on April 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to receive services that will help regain their previous functional status. The Plan denied your request. The Plan 
says the enrollee's needs can be met at an alternate level of 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 there are no acute rehab nursing needs identified or documented. The enrollee's 
nursing, and medical needs do not require an acute hospital inpatient rehab stay with an interdisciplinary 
approach to rehabilitative care. While the enrollee may benefit from physical and occupational therapy, the 
enrollee's rehab needs can be provided in a lower intensity and alternate setting such as in a skilled nursing 
facility. 
 
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. You say that the enrollee will benefit from acute inpatient rehab 
services that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says 
while the enrollee will likely benefit from ongoing therapy to enhance their rehabilitation potential, there is no 
evidence that this cannot safely be done at a lower level of 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
September 4, 2022. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported. 
 
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 physician 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 initial hospital care services. Our reviewer says that 
the documentation does not support that the code billed is supported. Our reviewer found the enrollee was 
evaluated after a fall. The evaluation revealed a closed head injury, facial fracture, and C7 fracture. The 
evaluation and management code billed requires a comprehensive history, a comprehensive examination and 
medical decision making of high complexity. However, the medical records submitted did not support a 
comprehensive history and comprehensive examination. Therefore, code 99223 is not supported. 
 
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 initial hospital care services have not been met. Therefore, we decided that 
the Plan does not have to pay for the initial hospital care services coded 99223 provided on September 4, 2022.