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 the enrollee's maximum function could be seriously 
jeopardized if IRF admission is not approved. 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 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 the enrollee's rehabilitation needs can be met safely and provided at a lower 
intensity and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (96127) provided October 
4, 2021. 
 You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another 
code 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, we have confirmed that code 96127 
is a column II code to column I code 99443. 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 outpatient mental health services (96127) provided October 4, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 9, 
2021, billed with code 99284. 
 
You asked the Plan to pay for the ED services as billed. You say that these are two separately payable visits. 
The Plan denied your request. The Plan says a valid modifier was not used to bypass the edit.  
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 99284 
is a column II code to column I code 99285, which was provided by another physician at the same billing 
group.  
 
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 
emergency department (ED) services provided on June 9, 2021, billed with code 99284.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chemotherapy services provided on January 
10, 2022. 
 
You asked the Plan to waive the cost share for chemotherapy services. You say that you believe the claim was 
processed incorrectly because you never had an outstanding copay charge. The Plan denied your request. The 
Plan says coinsurance is correct. 
 
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 20% 
coinsurance for Medicare Part B drugs, including chemotherapy drugs and $295 copayment for each in-
network outpatient hospital facility visit.  
 
  You have been asked to pay $3,661.50 for chemotherapy services. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
January 10, 2022 Chemotherapy $16,919.77 20% $3,383.95 
January 10, 2022 Outpatient hospital 
visit 
$295 $295 $277.55 
Total    $3661.50 
 
The chemotherapy services fall within the Medicare Part B prescription drugs and Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit categories. 
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 cost share for chemotherapy services provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician visit provided on March 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the physician visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 physician visit at issue in this appeal. The Plan did not pre-approve the 
physician visit. We found no exception that would require the Plan to pay the physician visit. The records 
provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that 
the Plan does not have to pay for the physician visit provided on March 2, 2022, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the admission for the inpatient stay provided from February 
1, 2021, to February 4, 2021. 
 
You asked the Plan to pay for the inpatient stay. You say that you are requesting the Plan issue a retrospective 
authorization for the services that were provided. You also say that the services were medically necessary. The 
Plan denied your request. The Plan says the inpatient stay was not medically necessary. 
 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 the inpatient stay. 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 record did not show that at the time of the inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier emergency department 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 the the inpatient stay have not been met. Therefore, we decided that the Plan 
does not have to pay for the admission for the inpatient stay provided from February 1, 2021, to February 4, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90836) provided January 3, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the records do not support the billed service. 
 
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 90836 is psychotherapy. 
 
We find that CPT code 90836 is not supported in the medical record. Specifically, the records provided do not 
detail the psychotherapy services. The record does not show how much time was spent on the psychotherapy.  
Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not 
been met. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90836) 
provided January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injection services. 
 
You asked the Plan to pre-approve sacroiliac joint injection services. You say that you cannot perform 
activities of daily living due to your pain levels. You say that pain medication is not helping you and you have 
gotten these requested injection services in the past. The Plan denied your request. The Plan says the requested 
injection services are not medically necessary because the enrollee only obtained a one day 50% improvement 
in pain after the April 2022 sacroiliac injections and possibly no relief following the February 2022 injection. 
 
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 sacroiliac joint injection services. Our 
reviewer says that sacroiliac joint injection services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a medical history of low back and hip pain.  She has 
been treated with medical therapy including narcotics, a home exercise program, and chiropractic care.  She 
received bilateral sacroiliac joint injections on April 7, 2022, which provided 50% relief of pain. Her provider 
has recommended another sacroiliac joint (SIJ) injection. The clinical value and effectiveness of an SIJ 
injection in the absence of tenderness and negative provocative testing results have not been demonstrated in the peer-reviewed literature. In this case, there is no documentation on physical examination of tenderness of 
the SIJ and no mention of SIJ provocative testing being completed with positive 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 sacroiliac joint injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve sacroiliac joint injection services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment from May 23, 2022 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment from May 23, 2022 forward. 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 from May 23, 2022 forward. 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 treatment in an 
acute inpatient mental health treatment beyond the date in question of May 24, 2022 forward and could have 
been treated in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or 
visual hallucinations and was not showing any aggressive behaviors. He was being cooperative and compliant. 
 
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 from May 23, 2022 forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment from May 23, 
2022 forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services requiring the presence of an 
independent trained observer (99152) billed for date of service March 1, 2021. 
 
You asked the Plan to pay for moderate sedation services. You say that you have provided records to support 
the service billed. The Plan denied your request. The Plan says the available records do not support the service 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the available medical 
records do not record the presence of an independent trained observer. Based on this information, we decided 
that Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that 
the Plan does not have to pay for moderate sedation services requiring the presence of an independent trained 
observer (99152) billed for date of service March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance used with a therapeutic CGM device 
(K0553) provided January 10, 2022. 
 
You asked the Plan to pay for the supply allowance. You say that the use of CGM's may allow patients to 
proactively treat their diabetes and prevent the need for hospital based diabetic care. The Plan denied your 
request. The Plan says the documentation submitted did not sufficiently support the billed supply code. 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the supply allowance. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Plan requires that the enrollee is taking at least 3 insulin doses per day and adjusting doses 
according to blood glucose levels.  There is no evidence that she is taking a fast-acting insulin or is adjusting 
her insulin doses based on blood glucose levels. This does not mean that the enrollee would not benefit from a 
CGM, but it does mean that the Plan criteria for CGM coverage are not met 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 supply allowance have not been met. Therefore, we decided that the Plan 
does not have to pay for supply allowance used with a therapeutic CGM device (K0553) provided January 10, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 1, 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 were not billed correctly. 
 
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 these 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 the laboratory services rendered on February 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 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 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 enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee 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 enrollee 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stiolto Respimat (J3535). 
 
You asked the Plan to pre-approve Stiolto Respimat. The Plan denied your request. The Plan says this drug is 
not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Stiolto Respimat (J3535).  
 
 
 
 
 
 Benefits for Stiolto Respimat 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you received oral medications and had stable 
vital signs. You were independent with functional mobility including gait to 500 feet. No skilled therapy was 
recommended. You do not require skilled nursing or therapy services on a daily basis. You do not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and does 
not require transfer to an LTACH. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that your condition does not meet Medicare criteria for LTACH services. 
 
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 the drug testing provided on August 13, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says the POS code on the claim does not match the location at which the sample 
was collected. 
 
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 drug testing 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 drug testing provided on August 13, 2021.