Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you meet the criteria for admission to the 
LTACH and it is your right to the care. The Plan denied your request. The Plan says criteria for admission to 
the LTACH have not been met. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively 
only on an inpatient basis. 
 
 
 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services provided on July 7, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry 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. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the documentation does not support a separate and distinct laboratory service from the 
other performed/billed service. Based on this information, we decided that Medicare rules for coverage of 
services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay 
for the mass spectrometry and tandem mass spectrometry services provided on July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lambswool sheepskin pad (E0189) and a continuous 
passive motion exercise device (E0935) billed for dates of service from May 20, 2022, to May 30, 2022. 
 
You asked the Plan to pay for a lambswool sheepskin pad and a continuous passive motion exercise device. 
You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The 
Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a lambswool sheepskin pad (E0189) and a continuous passive 
motion exercise device (E0935) billed for dates of service from May 20, 2022, to May 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services coded as 36415, 
80053, 80061, and 84439 provided August 10, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you thought your copay 
for labs would be $0.00. Had you known they were taking them to the hospital, maybe you would have refused 
to get them done there. 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 $40 
copayment for laboratory services in an outpatient hospital. 
 
You have been asked to pay $40 copayment for the laboratory services. This item/service falls 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 laboratory services coded as 36415, 80053, 80061, and 84439 provided August 
10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64494 billed for date of service June 24, 
2022. 
 
You asked the Plan to pay for procedure code 64494. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64494 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64494 billed for date of service June 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for procedure code 76937. You say that this service was billed appropriately. The 
Plan denied your request. The Plan says this service is an add-on code which was billed without an appropriate 
primary procedure. 
 
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 
procedure code 76937 is an add-on code and has not been billed with an appropriate primary procedure code. 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 76937 billed for date of service March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on June 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99221) provided on January 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the 
POS code to be used by the physician or other supplier will be assigned as the same setting in which the 
beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital 
inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported 
regardless of where the face-to-face service takes place. 
 
We looked at the file and Medicare rules. The records show that the enrollee was under outpatient status when 
the requested services were provided. As such, it is inappropriate to bill these services with an inpatient place 
of service. 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 the services (99221) provided on 
January 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 15, 2022, 
to March 16, 2022. 
 
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. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted for the billed 
dates of service. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered 
from February 15, 2022, to March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve these services. You say that chiropractic services are medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 these services.  Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that in 
this case, the record indicates that you have lumbar back pain with radiculopathy. The record does not indicate 
the presence of a subluxation of the spine demonstrated either by physical examination or radiographically. The 
elements of the coverage criteria are not satisfied. The requested services are not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services with DRG 871, provided from November 18, 
2021, to November 26, 2021. 
 
You asked the Plan to pay for the inpatient services with DRG 871. The Plan denied your request. The Plan 
says that the billed DRG is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan made a coding determination based on medical records provided to 
them. However, the Plan did not include medical records in the case file. Without medical records for the 
inpatient stay, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
inpatient services with DRG 871, provided from November 18, 2021, to November 26, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from 
November 29, 2022, forward. 
 
You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that the enrollee needs 
continued inpatient psychiatric care. The Plan denied your request. The Plan says that a continued stay at the 
inpatient behavioral health level of care for this admission is not medically necessary beginning November 29, 
2022. 
 
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 a continued inpatient psychiatric 
admission. Our reviewer says that a continued inpatient psychiatric admission from November 29, 2022, 
forward is not medically necessary. Our physician reviewer found that based upon review 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 November 29, 2022. The enrollee could have been treated in a lesser restrictive setting as 
there was no evidence of 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. 
 
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 continued inpatient psychiatric admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from November 
29, 2022, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan  
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on May 28, 
2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says a valid proof of delivery 
was not provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The delivery ticket in this case does not show the items 
delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) 
provided on May 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on March 4, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 We looked at the file and Medicare rules. Payment for the requested services (J3490) is included in the global 
surgery payment for the procedure (20610) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan 
does not have to pay for the drugs (J3490) provided on March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve new eyeglasses. 
 
You asked the Plan to pre-approve new eyeglasses. You say that you have a severe change to your vision and 
need new glasses. You also say that you need the new glasses for driving and everyday activities. The Plan 
denied your request. The Plan says you last received eyewear on December 1, 2021. The Plan also says that 
you are not eligible for eyeglasses until December 1, 2022. 
 
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 offers a $175 vision allowance for routine contact lenses or eyewear every year. 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you last received eyewear on 
December 1, 2021, and at the time of this appeal, your eyewear benefit had been exhausted. Based on this 
information, we decided that the Plan's rules for coverage of new eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pre-approve new eyeglasses.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for Medicare Part B 
prescription drugs and diagnostic eye exams provided from August 17, 2021, to July 8, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for Medicare Part B prescription drugs and 
diagnostic eye exams. You say that you are requesting reconsideration because of hardship. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $20 copayment for Vision care.  
 You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $20 copayment 
for diagnostic eye exams. The total allowed amount for Medicare Part B drugs is $1,500. You are being asked 
to pay $300 ($1,500 x 20% = $300). You are being asked to pay $180 for the diagnostic eye exams ($20 x 9 
visits = 180). The total amount you are being asked to pay is $480 ($300 + $180 = $480). 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 and coinsurance for Medicare Part B prescription drugs and diagnostic 
eye exams provided from August 17, 2021, to July 8, 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 the enrollee exceeds criteria for an 
LTACH admission. The Plan denied your request. The Plan says criteria for admission to the LTACH have not 
been met. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
enrollees current acute care hospital. All medically necessary care is being provided in the current acute care 
setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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.