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 you are in need of acute inpatient rehabilitation and a 
lower level of care would not be appropriate. The Plan denied your request. The Plan says authorization denied 
because IRF care is not medically necessary, and your needs can be met at a lower level of care such as a 
skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and does not need close physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There are no rehabilitation nursing needs identified or documented in the record. 
 
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 inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of May 10, 2022, forward as this enrollee was not shown to be a danger to 
themself or others. They were not showing any auditory or visual hallucinations and was cooperative/compliant 
with treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute 
threats of safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
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 you are unable to function independently and needs 
therapy in order to build stamina and regain independence. The Plan denied your request. The Plan says 
authorization denied because the IRF care is not medically necessary, and your needs can be met at a lower 
level of care such as skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and do not need close physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There are no rehabilitation nursing needs identified or documented in the record. 
 
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 the drug testing services (G0483) provided on November 19, 
2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the records do not include the enrollee's 
history, physical exam findings, current treatment plan and how the tests results are needed to make cinical 
decisions about the enrollee's care. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the drug testing services (G0483) 
provided on November 19, 2021. have been met. Specifically, the documentation submitted does not include 
any clinical information. We are unable to determine why this testing was ordered, if it was medically 
necessary or how the results will effect the enrollee's treatment. Therefore, we decided that the Plan does not 
have to pay for the drug testing services (G0483) provided on November 19, 2021.
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 exceeds the CMS guidelines 
for LTACH care and requires hospitalization. The Plan denied your request. The Plan says authorization denied 
because the LTACH is not medically necessary, and the enrollee's needs can be met at a lower level of care 
such as a skilled nursing facility (SNF). 
 
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 appears to be more stable and improving and should only require 
short-term additional acute care services that can be safely completed at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have systolic congestive heart failure and are receiving intravenous inotropic and 
diuretic therapy. The record indicates that you require ongoing acute care services. You continue to receive 
acute care services, and these have not been denied. The medical record does not indicate that you require 
services that you are not currently receiving but that would be available at the LTACH 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150) provided January 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 (87150) provided January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81235, 81321) provided June 15, 2021. 
 
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 the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that  if one laboratory procedure evaluates multiple 
genes using a single next generation sequencing procedure, the laboratory shall only report one unit of service 
for the entire panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single genetic panel. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81206, 81235, 81321) provided June 
15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83970) provided June 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately. 
 
We looked at the file and Medicare rules. This service is included in the dialysis payment. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (83970) provided June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81162, 81191, 81206 81235, 81292) provided 
July 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 (81162, 81191, 81206 81235, 81292) provided July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contract language in place to indicate that these services are included in the dialysis rate. The Plan 
denied your request. The Plan says payment for lab services related to ESRD is included in the dialysis rate. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder arthroscopy with debridement (29822) provided 
on September 24, 2021. 
 
You asked the Plan to pay for the shoulder arthroscopy with debridement (29822). You say that you are 
requesting payment in full for the services rendered on this date. The Plan denied your request. The Plan says 
procedure codes 29826, 64415 and C9290 have been overturned. The Plan also says that procedure code 29822 
remains denied as the documents do not support the procedure was distinct or independent from other services 
performed. 
 
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 29822 is a column II code to column I code 29824 and 29827; 
however, 29822 was 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 the shoulder arthroscopy with debridement (29822). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the operative report describes arthroscopic procedures performed on the left shoulder. If 
another arthroscopy procedure is billed and paid for on the same day, on the same shoulder, at the same 
encounter, the limited debridement (code 29822) is not separately payable. 
 
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 shoulder arthroscopy with debridement (29822) have not been met. 
Therefore, we decided that the Plan does not have to pay for the shoulder arthroscopy with debridement 
(29822) provided on September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from November 22, 2021, to 
December 1, 2021, as billed with Diagnosis Related Group (DRG) 853. 
 
You asked the Plan to pay for inpatient care billed with DRG 853. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 853 is not supported as the diagnosis of sepsis is not supported in the medical record. The Plan argues that DRG 477 is 
more appropriate in this case with osteomyelitis as the principal diagnosis. 
 
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. 
 
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 inpatient care billed with DRG 853. Our 
reviewer says that the diagnosis of sepsis is not supported in the medical record for this inpatient admission. 
Our physician reviewer found that the enrollee presented to the emergency department on November 22, 2021, 
after being referred by her Podiatrist due to foot pain. The enrollee had a history of multiple fractures in her 
right foot one year ago and was treated nonoperatively, but recently developed an abscess to the right foot 
which her Podiatrist attempted treatment with oral antibiotics with no improvement. She also developed 
Charcot arthropathy and worsening abscess. There was no documentation of sepsis. The review has determined 
that the medical records did not support the billing of sepsis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 853 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from November 22, 2021, to December 
1, 2021, as billed with Diagnosis Related Group (DRG) 853.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 23, 2021 
to October 24, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says there is no referring 
provider on file. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the ED on 10/23/2021 after a pre-syncopal event. He was 
evaluated in the ED. His labs were normal; CXR demonstrated multifocal infiltrates. He was admitted and 
evaluated by Neurology. His condition stabilized and improved and he was discharged home on 10/24/2021. 
The review has determined that the record did not that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 23, 2021 to October 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services have not been billed 
correctly. 
 
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 looked at the file and Medicare rules. We find that the various denied CPT codes are not supported in the 
medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Based on 
this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 15, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ingrezza. 
 
You asked the Plan to pre-approve Ingrezza. The Plan denied your request. The Plan says Ingrezza to be 
administered at home is not covered under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ingrezza.  
 
 
 Benefits for Ingrezza 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan services coded as 
74176 provided on January 16, 2022. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
no the medical records. The Plan denied your request. The Plan says an appropriate modifier was not billed 
with this code as required for payment. 
 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 74176 
is a column II code to column I code 74177. 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 the computed tomography (CT) scan services coded as 74176 
provided on January 16, 2022.