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

 
We decided that the Plan does not have to pay for procedure code 99220 billed for date of service May 20, 
2021, procedure code 99226 billed on dates of service May 21, 21, and May 22, 21, and procedure code 99217 
billed for date of service May 23, 2021. 
 
You asked the Plan to pay for procedure codes 99217, 99220, and 99226 (x2). You say that the medical records 
support payment of these codes. The Plan denied your request. The Plan says these codes are not supported in 
the medical record. 
 
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 99217 us is observation care discharge.  The definition of 
code 99220 is initial observation care; comprehensive history; comprehensive exam; medical decision making 
of high complexity.    
The definition of code 99226 is subsequent observation care, detailed interval history; detailed examination; 
medical decision making of high complexity  
 
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 99217, 99220, and 99226 (x2). Our 
reviewer says that the medical records do not support payment for these codes. Evaluation and management 
services were reported, and the record does not include documentation to support observation status.  Our 
reviewer found for each of these codes, the medical record notes that the patient was admitted to hospitalist 
service for further evaluation and management.  However, for each code, a query would be made before 
reporting services. This was not reflected in the medical record. 
 
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 99217, 99220, and 99226 (x2) have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 99220 billed for date of service May 20, 
2021, procedure code 99226 billed on dates of service May 21, 21, and May 22, 21, and procedure code 99217 
billed for date of service May 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF is not medically necessary and the enrollee's needs can be met at a 
lower level of care such as in a skilled nursing facility. 
 
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 while the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program that an IRF would provide. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subarachnoid injection (62320) provided on December 13, 
2021. 
 
You asked the Plan to pay for injection procedure. You say that Medicare covers this code with no diagnosis 
code limitation. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the records submitted are not sufficient to support this service. 
 
The Plan must follow Medicare rules. Medicare rules say that code 62320 is not covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of injection procedure have not been met. Therefore, we decided that the Plan does not have to pay 
for a subarachnoid injection (62320) provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on October 
26, 2021. 
 
You asked the Plan to pay for code 99233. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
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. In this case, there were no medical records provided confirming that three separate subsequent hospital care (99233) services were provided by this provider on October 26, 2021. 
The file shows that the Plan paid for one claim submitted with code 99233 by this provider. Therefore, we 
decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on October 26, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided to the enrollee on 
December 20, 2021. 
 
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 plan has not received the required clinical records to support the medical necessity of this 
service.  
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 pain management services provided to 
the enrollee on December 20, 2021. have been met. The records sent in by the provider are incomplete, as they 
are unsigned and undated. The services cannot be verified in this case.. Therefore, we decided that the Plan 
does not have to pay for pain management services provided to the enrollee on December 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient detox treatment. 
 
You asked the Plan to pre-approve inpatient detox treatment. You say that the requested inpatient detox 
treatment is medically necessary. The Plan denied your request. The Plan says the requested inpatient detox 
treatment does not meet criteria. 
 
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 detox treatment. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found it did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or for the purpose of diagnosis. I am unable to find an individualized treatment plan. Based upon review the 
records provided, the enrollee does not meet the criteria for treatment in an acute inpatient mental 
health/detoxification treatment beyond the date in question of May 20, 2022 forward and could have been 
treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or 
visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and 
compliant while not showing any acute threats to safety. He was no longer showing any withdrawal symptoms. 
 
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 detox treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient detox treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided to the enrollee on 
November 15, 2021. 
 
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 plan has not received the required clinical records to support the medical necessity of this 
service.  
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 pain management services provided to 
the enrollee on November 15, 2021 have been met. The records sent in by the provider are incomplete, as they 
are unsigned and undated. The services cannot be verified in this case. Therefore, we decided that the Plan does 
not have to pay for pain management services provided to the enrollee on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided to the enrollee on 
November 8, 2021. 
 
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 plan has not received the required clinical records to support the medical necessity of this 
service. 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 pain management services provided to 
the enrollee on November 8, 2021 have been met. The records sent in by the provider are incomplete, as they 
are unsigned and undated. The services cannot be verified in this case. Therefore, we decided that the Plan does 
not have to pay for pain management services provided to the enrollee on November 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the 
cervical spine with contrast. 
 
You asked the Plan to pre-approve an MRI scan of the cervical spine with contrast. You say that the requested 
service is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for 
the requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 an MRI scan of the cervical spine with 
contrast. Our reviewer says that the requested service is not medically reasonable and necessary in this case. 
Our physician reviewer found that you have already had a cervical MRI. There is no clinical information to 
support the need for a second MRI with contrast. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan of the cervical spine with contrast have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the 
cervical spine with contrast.
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 currently stable for discharge from the 
inpatient hospital setting and IRF admission is medically necessary. The Plan denied your request. The Plan 
says IRF is not medically necessary and the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care such as at a skilled nursing facility, on an intermittent basis at home with 
home health care, or in a long-term care setting. 
 
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 while the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program such as an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided to the enrollee on 
November 1, 2021. 
 
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 plan has not received the required clinical records to support the medical necessity of this 
service.  
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 pain management services provided to 
the enrollee on November 1, 2021 have been met. The records sent in by the provider are incomplete, as they 
are unsigned and undated. The services cannot be verified in this case. Therefore, we decided that the Plan does 
not have to pay for pain management services provided to the enrollee on November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary as the enrollee 
is in danger of not regaining maximum function. The Plan denied your request. The Plan says IRF care is not 
medically necessary and the enrollee's needs can be met at a lower level of care such as in a skilled nursing 
facility or at home with home health services. 
 
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 while the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the member needs 24 hour nursing, physician 
oversight for his chronic medical conditions and physical and occupational therapy. The Plan denied your 
request. The Plan says that the enrollee can safely receive the services he needs in other settings. 
 
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. The 
enrollee is medically stable and has no medical complexity and does not need physical medicine and rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no rehab nursing needs identified or 
documented in the record. At the current functional status, the enrollee does not need 3 hours a day five days a 
week of IRF therapies with interdisciplinary management. The enrollee needs physical and occupational that 
can be provided in a lower intensity setting. The enrollee is stable with no medical complexity. The complexity 
of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient rehab stay 
with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have doctors 
appointments weekly that you need transportation to. The Plan denied your request. The Plan says that you 
have exceeded your benefit limit. 
 
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 forty-eight (48) trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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: Drugs
Decision: Favorable

 
We decided that the Plan does not have to pre-approve Gamunex IV. 
 
You asked the Plan to pre-approve Gamunex IV. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the criteria for coverage of the requested drug 
have 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 Gamunex IV. Our reviewer says that 
the criteria for coverage have been met. Our physician reviewer found the enrollee's status post deceased donor 
kidney transplant is complicated by BK Virus infection. The BK virus infection is a complication of the 
immunosuppressive medications. IVIG along with Cidofovir are standard therapy for BK virus as a 
complication of kidney transplantation. The usage of the requested medication is standard of care and 
appropriate. 
 
 
 
 
 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex IV have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex IV.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary as the 
enrollee does not have anyone at home to take care of her. The Plan denied your request. The Plan says at the 
current level of function, the enrollee does not require daily skilled therapy services on an inpatient basis. 
Skilled services can be provided on an intermittent outpatient basis, in a long-term care facility, or in the home 
with home health care services.  
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.