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 well enough to be treated and do not need 
hospice. The Plan denied your request. The Plan says the services you need can be provided safely in another 
setting such as, a skilled nursing facility or 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 you do 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for incision and drainage of abscess (eg, carbuncle, suppurative 
hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple 
provided to the enrollee on July 2, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the code is not appropriate for the services billed, as the medical records indicate that a 
simple incision and drainage was 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, the CPT Code Manual definition of 
code 10061 is "Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or 
subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that based on the procedure report, the 
medical records support that this denied code was rendered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, 
cyst, furuncle, or paronychia); complicated or multiple provided to the enrollee on July 2, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 11, 2022, and 
May 9, 2022. Therefore, we decided that the Plan does not have to pay for the dental services on September 13, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and 
pelvis (74178). 
 
You asked the Plan to pre-approve a CT of the abdomen and pelvis. The Plan denied your request. The Plan 
says they were unable to make a decision within the appeal timeframe. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT of the abdomen and pelvis. Our 
reviewer says that a CT of the abdomen and pelvis is not medically reasonable and necessary for the enrollee. 
Our physician reviewer found there are no reports from any imaging studies done in the past, but there is a note 
stating a simple right renal cyst was seen on a CT on March 20, 2016. If indeed the right renal cyst was simple, 
as stated in the notes, a right renal ultrasound would be the initial step in evaluation. Our reviewer found that 
without seeing the actual reports of the imaging studies already done in the past, a determination that CT would 
be necessary cannot be made. Also, there is no mention of any symptom with respect to the pelvis to justify a 
CT of the pelvis. Our physician reviewer also found that without seeing the actual reports of past imaging 
studies, the medical necessity of the requested CT of the abdomen and pelvis cannot be established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT of the abdomen and pelvis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and pelvis (74178).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of the right brow ptosis.  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says no pseudo-MRD was submitted, and a second photograph should document 
improvement by manual elevation of the brows of dermatochalasis procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient does have functional right eyelid blepharoptosis ("true ptosis") of which 67903 
blepharoptosis repair has been approved. However, patient does not have "pseudo-ptosis" caused by excessive 
eyelid skin warranting a brow ptosis repair (67900). Manual lifting of the right eyebrow (as demonstrated in 
photographs) will not have a significant improvement in eyelid position if blepharoptosis ("true ptosis") is 
present and there is no excessive redundant eyelid skin contributing to the eyelid ptosis, ie, "pseudo-ptosis." 
With right eyebrow lifted and taped, the MRD1 is 1mm.  This demonstrates there is blepharoptosis ("true 
ptosis") and a blepharoptosis repair (67903) is medically necessary, as is already pre-approved. However, there 
is no medical indication shown on clinical notes and/or photographs for brow ptosis repair (67900). 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repair of the right brow ptosis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the eyeglasses you purchased and the eye 
examination you received on August 29, 2022, from an out-of-network provider. 
 You asked the Plan to reimburse you for eyeglasses and eye examination. You say that you thought the 
service/items would be covered. The Plan denied your request. The Plan says the eye examination was paid in 
full directly to the provider. The Plan paid the full $180 for they eyeglasses from a non-participating provider 
and you are responsible for the additional charges. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of eyeglasses and eye examination have not been met. The Plan paid in full directly to the provider 
for the eye examination. You have a $0 copayment for an annual routine eye examination, so you should not be 
charged for the eye examination. The Plan paid $180 for the eyeglasses and the remainder is your 
responsibility. Therefore, we decided that the Plan does not have to reimburse you for the eyeglasses you 
purchased and the eye examination you received on August 29, 2022, from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for date of service July 25, 
2022. 
 You asked the Plan to pay for procedure code 99215. You say that you have submitted a corrected claim and 
would like 99205 removed. The Plan denied your request. The Plan says payment for code 99215 is bundled 
into payment for code 99205. 
 
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 99215 
is a column II code to column I code 99205. 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 procedure code 99215 billed for date of service July 25, 2022.  
 
Please note that this decision is limited to the Plans denial based on your initial claim submission.  If you have 
submitted a corrected claim and need more information about it, please contact the Plan directly.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 16, 2022, to 
May 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that an invalid NOA with an admission 
date of April 21, 2021, was received on March 28, 2022. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from April 16, 2022, to May 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetic testing services provided on July 28, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records document all billed charges. 
The Plan denied your request. The Plan says the records do not show what medications the provider is 
considering. 
 The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under 
certain medical indications. 
 
We looked at the file and Medicare rules. The pharmacogenetic testing was reportedly ordered to make 
decisions about the enrollees medications. Medications should be provided based on the presence of a 
diagnosis and should be adjusted based on the enrollees response to the medication. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for the pharmacogenetic testing services provided on July 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 14, 2022, to 
September 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that an invalid NOA with an admission 
date of April 21, 2021, was received on March 28, 2022. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from August 14, 2022, to September 12, 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 your doctor said you need this type of 
facility. The Plan denied your request. The Plan says you are receiving medically necessary acute and/or 
critical care and do not have clinical conditions that cannot be appropriately treated in the current hospital. 
 
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 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 laboratory services provided on April 23, 2021. 
 
You asked the Plan to pay for laboratory services. You say that you paid $322.02 instead of $179 and would 
like the Plan to reimburse you the amount overpaid. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on April 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services provided on October 5, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that the enrollee had to go to a 
different facility for these services. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for lab services when provided in an outpatient hospital facility.   
 
You have been asked to pay a $26.45 copayment for the lab services because the allowed amount for these 
services is less than $40. These items/services fall within the outpatient diagnostic tests and therapeutic 
services and supplies 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 copayment for the lab 
services provided on October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need more hours of rehabilitation due to your 
declining health The Plan denied your request. The Plan says you do not meet the criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found while you may need physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 There is not a reasonable expectation that 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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that the service is necessary. The Plan denied your request. 
The Plan says the requested service is 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 pre-approve a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of a TTE which was described as unremarkable. The enrollee has no 
cardiac symptoms. Documentation at this time would not point to a change in status that would support the 
medical necessity of a repeat TTE. Clinical guidelines do not support repeating a TTE with no intervening 
change in clinical status or new signs, symptoms or physical findings. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiogram (TTE) (93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
August 22, 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 are not payable as billed. 
 
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 find that CPT code 99223 is not supported in the medical record. Specifically, this service was not billed 
with a valid place of service. 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 August 22, 2022.