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 IRF care is medically reasonable and necessary. 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 was admitted for chest pain, cardiac arrest, and coronary artery 
bypass grafting. 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 pay for continued inpatient services at a long-term acute care 
hospital (LTACH) from October 16, 2021, to October 31, 2021. 
 
You asked the Plan to pay for the LTACH services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this higher level of care was not needed. 
 
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 pay for the LTACH services. Our reviewer says that 
the requested ongoing LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appeared to have been more stable and improving on 10/16/21. The 
patient did not require services at the LTACH that were not already available at a lower level of care such as 
skilled nursing facility (SNF). Ongoing care at LTACH from 10/16/21 to 10/31/21 is not medically necessary as transfer to SNF at that time would have been more clinically appropriate based on the provided 
documentation. 
 
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 pay for continued inpatient services at a long-term acute care hospital (LTACH) from October 
16, 2021, to October 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9359) provided on  
October 18, 2021. 
 
You asked the Plan to pay for the home infusion therapy (S9359). You say that the claim denied for requiring 
authorization, but you have confirmed authorization is not needed. The Plan denied your request. The Plan says 
the billed code is not valid for Medicare purposes. 
 
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 S9359 is home infusion therapy, anti-tumor necrosis 
factor intravenous therapy; (e.g., infliximab); administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
  We find that CPT code S9359 is not supported in the medical record. Specifically, CPT code S9359 has a status 
indicator of I. This means that CPT code S9359 is not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of the home infusion therapy (S9359) have not been met. 
Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9359) provided on 
October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Gonioscopy (92020) provided on November 23, 2021. 
 
You asked the Plan to pay for code 92020. You say that you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says the enrollee received a Gonioscopy test coded as 92020 that is not 
covered by Medicare or the Plan. 
 
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, the Plans contract, and Medicare rules. Medicare will cover glaucoma screenings for 
high-risk patients only coded as G0117 or G0118. In this case, the file shows that the enrollee received a 
Gonioscopy coded as 92020. This code is not a covered code under Medicare for screening glaucoma or the 
Plans supplemental vision benefit. Based on this information, we decided that the Plan's rules for coverage of 
code 92020 have not been met. Therefore, we decided that the Plan does not have to pay for the Gonioscopy 
(92020) provided on November 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient psychotherapy services to be provided by a 
licensed professional counselor (LPC). 
 
You asked the Plan to pay for the LPC services. You say that it is felt that this care is necessary. The Plan 
denied your request. The Plan says the requested type of provider is not able to be paid by Medicare directly for 
covered services. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. LPCs are not eligible to enroll in the Medicare program. Therefore, we decided that the Plan does not 
have to pay for outpatient psychotherapy services to be provided by a licensed professional counselor (LPC).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiology services (procedure code 75625) provided to the enrollee on 
November 23, 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 that [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."] 
 
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 75625 is "Aortography, abdominal, by serialography, radiological supervision and interpretation." 
 
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 the procedure notes document completely 
the performance of an abdominal aortagram, and the findings of the same. This procedure conforms to the 
requirements to reimburse CPT 75625. 
 
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 
radiology services (procedure code 75625) provided to the enrollee on November 23, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you require this in order to facilitate bathing. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for wheelchair van transport and supplies provided on 
April 28, 2021. 
 
You asked the Plan to reimburse you for the wheelchair van transport and supplies. You say that you are 
currently immobile and must use a company that is accessible for wheelchair transportation to medical 
appointments. The Plan denied your request. The Plan says an itemized bill was requested and not received. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services. Medicare rules also 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. 
 The services you have asked the Plan to reimburse you for are wheelchair van transport services. Additionally, 
the file does not include an itemized bill. Therefore, we decided that the Plan does not have to reimburse you 
for wheelchair van transport and supplies provided on April 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency wheelchair van transport provided on 
October 26, 2021. 
 
You asked the Plan to pay for the transportation service. You say that you are unable to safely transfer from 
your wheelchair to personal vehicle. The Plan denied your request. The Plan says wheelchair van transport is 
not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
 
 
 
 
 The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the non-emergency wheelchair van transport provided on  
October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on  
February 4, 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 denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 33418: 
 
Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; 
initial prosthesis 
 
CPT 99152: 
 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 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 not supported by the medical records. Our reviewer found CPT 33418 was billed with an 
incorrect modifier, and cannot be verified. In terms of CPT 99152, the operative report does not include 
documentation of an independent trained observer, per CPT code description, to confirm this procedure has 
been performed. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on February 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided the enrollee on May 22, 2021. 
 
You asked the Plan to pay for the services. You say that the patient was on hospice from 5/2/21 through 5/7/21. 
The Plan denied your request. The Plan says the claim is the responsibility of Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on May 7, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided the enrollee on May 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided to the enrollee from October 
21, 2021, to October 29, 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 non-contracted provider did not get authorization for these services. 
 
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 office visit services provided to the enrollee from 
October 21, 2021, to October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99239) provided August 12, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management of more 
than 30 minutes. 
 
 
 
 We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show 30 
minutes or more were spent on this service. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay 
for physician services (99239) provided August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (codes 82727, 83540, 83540, 83550, and 83970) 
provided on October 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract in place to include these 
labs in the dialysis rate, so these lab services should be paid. The Plan denied your request. The Plan says these 
services are not separately payable for an End Stage Renal Disease (ESRD) patient. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services furnished ESRD patients are 
included in the ESRD Prospective Payment System as Part B services and are not paid separately. If the lab 
services are furnished for reasons other than for the treatment of ESRD, the provider should bill separately 
using the AY modifier. 
 
In this case, the patient is an ESRD patient.  You did not bill these lab services with an AY modifier to indicate 
that they were furnished for any reason other than ESRD treatment.  According to Medicare rules, these lab services are not separately payable as billed. Therefore, we decided that the Plan does not have to pay for lab 
services (codes 82727, 83540, 83540, 83550, and 83970) provided on October 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on November 
19, 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 Medicare rules for payment of this claim have not been followed. 
 
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 A0425 is "Ground mileage, per statute mile." 
 
We find that CPT code A0425 is not supported in the medical record. Specifically, the MUE for this code is 
250. As this is the case, the code cannot be paid as the billed units exceed this. 250 units have already been 
paid. 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 pay for ambulance services provided to the enrollee on 
November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusions (99601 and 99602) provided on October 
18, 2021. 
 
You asked the Plan to pay for the home infusions (99601 and 99602). You say that no authorization is required 
for CPT code 99601 and 99602. You say that these codes have been previously paid, and the codes should be 
reimbursed for $210. The Plan denied your request. The Plan says the billed codes are not valid for Medicare 
purposes. 
 
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 99601 is home infusion/specialty drug administration, per 
visit (up to 2 hours). The CPT Code Manual definition of code 99602 is home infusion/specialty drug 
administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary 
procedure).  
 
We find that CPT code 99601 and 99602 are not supported in the medical record. Specifically, CPT codes 
99601 and 99602 have a status indicator of I. This means that CPT codes 99601 and 99602 are not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home 
infusions (99601 and 99602) have not been met. Therefore, we decided that the Plan does not have to pay for 
the home infusions (99601 and 99602) provided on October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on  
November 18, 2021. 
 
You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan 
says the procedure code (CPT 29999) is not supported in the medical records submitted. 
 
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 29999 is "unlisted arthroscopy procedure." 
 
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 . Our reviewer says that the services at issue in this case were 
not supported by the medical records. Our reviewer found the operative note does not describe the unlisted 
procedure. The correct coding would be for shoulder arthroscopy, rather than an unlisted procedure. 
 
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of  have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical services provided to the enrollee on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on  
March 10, 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 Medicare rules say that specimen validity testing is not covered separately. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 The services at issue in this case are for the purpose of specimen validity testing. 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 pay for laboratory services provided to the enrollee on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to further reimburse you for a second pair of eyeglasses purchased on 
September 30, 2021. 
 
You asked the Plan to further reimburse you for a second pair of eyeglasses. You say that you would like to be 
further reimbursed up to the Plan's allowance for the eye wear you purchased. The Plan denied your request. 
The Plan says reimbursement is limited to one pair of eyeglasses. 
 
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. The Plan covers up to one pair of eyeglasses a year. 
 
We looked at the file and the Plan's rules. In this case, this request is for a second pair of eyeglasses which 
exceeds the Plans eyeglass benefit. Based on this information, we decided that the Plan's rules for coverage of 
a second pair of eyeglasses have not been met. Therefore, we decided that the Plan does not have to further 
reimburse you for a second pair of eyeglasses purchased on September 30, 2021.