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

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided February 18, 
2021. 
 
You asked the Plan to pay for the office visit. You say that kindly review the attached medical records and you 
request processing of the denied codes towards payment as soon as possible. The Plan denied your request. The 
Plan says there is evidence of misrepresented services. 
 
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 outpatient office visit (99202) 
provided February 18, 2021 have been met. There is no evidence of an established relationship between the 
enrollee and the physician. The records show that the Plan had made multiple attempts to obtain medical 
records from the provider without success. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit (99202) provided February 18, 2021.
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 have been extremely ill since late February and 
are weak but eager to regain your strength. You state you are requesting admissions so that you can fully 
recover and return home. The Plan denied your request. The Plan says the stay is not medically necessary based 
on IRF criteria. The Plan states you can safely receive the services you need in other settings, for example: 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and hyponatremia. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you 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.
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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care 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 that the patient has a past medical history of lumbar radiculopathy, atrial fibrillation, 
diabetes, and hypertension and is living at home with weakness and debility. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this 
patient 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: 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 does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. The 
enrollee's rehab can be safely provided at a lower intensity and alternate setting such as a skilled nursing 
facility or in-home with therapies. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically appropriate for this 
patient. He is still vent-dependent and will require vent weaning at the LTACH. The Plan denied your request. 
The Plan says the patient can safely get needed care at the current acute 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 the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical 
assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and 
improve with, LTACH services. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee at this time. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on February 8, 2021. 
 
You asked the Plan to pay for the telehealth visit. You say that the attached records should be reviewed, and the 
codes processed toward payment. The Plan denied your request. The Plan says there is no established 
relationship with the ordering provider. 
 
  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 telehealth visit have been met. 
Specifically, the documentation does not support an established relationship with the provider and enrollee. 
Therefore, we decided that the Plan does not have to pay for the telehealth visit provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urgent care visit provided on November 21, 2020. 
 
You asked the Plan to pay for the urgent care visit. The Plan denied your request. The Plan says the provider 
submitted this claim after timely filing limitations. 
 
The Plan follows Medicare rules. The 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. 
 
The record shows that a claim for the urgent care visit was not filed until November 22, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the urgent care visit provided on November 21, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that the requested 
transportation trips are medically necessary in order to get to your dialysis treatments. The Plan denied your 
request. The Plan says the benefit for routine transportation trips has been exhausted. 
 
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 a maximum of 24 one-way routine transportation trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The case file shows that you have 
received coverage for 24 one-way routine transportation trips in the 2022 calendar year. Based on this 
information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for fentanyl citrate injection 
pump refills provided from September 22, 2021, to November 8, 2021. 
 
You asked the Plan to waive the copayments and coinsurance for the injection refills. You say that you feel that 
you are now being charged for the full amount of the medication refills. The Plan denied your request. The Plan 
says the correct copayments and coinsurance were applied. 
 
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 $45 copayment for surgery services received in a specialist's office. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs, including 
pain management drugs. 
 
Drug/Service Allowed Amount Copayment 20% Coinsurance 
Pump Refill/Analysis  September 22, 2021 - $45.00 - 
Fentanyl Citrate  September 22, 2021 $63.00 - $12.60 
Pump Refill/Analysis  October 7, 2021 - $45.00 - 
Fentanyl Citrate  October 7, 2021 $32.48 - $6.50 
Pump Refill/Analysis  October 30, 2021 - $45.00 - 
Fentanyl Citrate  October 30, 2021 $64.00 - $12.80 
Totals:  $135.00 $31.90 
 
You have been asked to pay $135 for the injection refill procedures. the injection refill procedures fall within 
the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been 
asked to pay $31.90 for the fentanyl citrate medication, which is 20% of the allowed amount. The medication 
falls within the Medicare Part B Prescription Drugs 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 
copayments and coinsurance for fentanyl citrate injection pump refills provided from September 22, 2021, to 
November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care discharge services rendered on August 
30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
 
 The provider submitted a claim for procedure codes 99217 (observation care discharge) and 99239 (hospital 
discharge day management). Code 99217 is a column II code with a modifier indicator of 1 when billed with 
column I code 99239. Code 99217 was not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the observation care discharge services rendered 
on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that services were provided to the enrollee so the claim 
should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no referral from an in-network provider or an approved authorization. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on June 28, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx panel provided on June 2, 2021. 
 
You asked the Plan to pay for the Guardant360 CDx panel. You say that POS code 81 is correct for this 
service. The Plan denied your request. The Plan says the POS code does not match where this sample was 
taken. 
 
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 Guardant360 CDx panel 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 the Guardant360 CDx panel provided on June 2, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ExoDX Prostate IntelliScore (EPI) test. 
 
You asked the Plan to pre-approve the EPI test. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that EPI testing is only covered in men who are over 
75 years old when their PSA is less than 10ng/ml.  
 
We looked at the file and Medicare rules. The records show that you are 81 years old and have a PSA of 12.0 
ng/ml. Based on this information, we decided that Medicare rules for coverage of the EPI test have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an ExoDX Prostate IntelliScore (EPI) 
test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that this item is necessary for the enrollee's condition. 
The Plan denied your request. The Plan says this is not a covered item according to Medicare rules. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas therapy rendered on March 12, 2021 to June 18, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the use of vasopneumatic devices may be considered 
reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema or 
lymphedema 
 
We looked at the file and Medicare rules. The file shows that the services were not rendered for the treatment 
of edema or lymphedema.  
 
 Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the Sanexas therapy rendered on March 12, 2021 
to June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care rendered on April 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99221 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 99221 (initial hospital care, per day, 30 minutes) and 
99222 (initial hospital care, per day, 50 minutes). Code 99221 is a column II code with a modifier indicator of 
1 when billed with column I code 99222. Code 99221 was not billed with an appropriate modifier to allow for 
separate payment. Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered 
on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TDAP vaccine provided on November 4, 2021. 
 
You asked the Plan to pay for the TDAP vaccine. You say that you are uploading providers notes for review. 
The Plan denied your request. The Plan says the Tetanus vaccination is excluded as immunization unless 
directly related to the treatment of an injury or direct exposure to a disease or condition. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. 
Therefore, we decided that the Plan does not have to pay for the TDAP vaccine provided on November 4, 
2021.  
 Benefits for the TDAP vaccine 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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for osteonecrosis and fracture of the mandible. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient 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.