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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Intravenous Infusion, hydration; each additional hour (list 
separately in addition to code for primary procedure) (96361) provided May 6, 2021 
 
You asked the Plan to pay for the infusion services. You say that please review the attached documentation for 
the denied charge 96361. The Plan denied your request. The Plan says payment for this is included in the 
payment for the chemotherapy administration or non-chemotherapy injection and infusion 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, We find that CPT code 96361 is not supported in the medical record. Specifically the fluid used to 
administer the drugs is incidental hydration and is not separately payable. Payment for this is included in the 
payment for the chemotherapy administration or non-chemotherapy injection and infusion service.Based on 
this information, we decided that Medicare rules for coverage of the infusion services have not been met. 
Therefore, we decided that the Plan does not have to pay for Intravenous Infusion, hydration; each additional 
hour (list separately in addition to code for primary procedure) (96361) provided May 6, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307, G0480) provided on August 4, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that most in-network providers cannot perform such 
complex detailed drug testing services. You also say that routine urine drug testing is necessary to monitor the 
use of the prescriptions as a part of the program. The Plan denied your request. The Plan says this provider is a 
non-network provider, and the member was referred by a provider who also does not work with the members 
plan. The Plan also says that the members primary care physician did not refer for services, and no medical 
necessity for an out-of-network provider, such as an urgent or emergency situation has been documented. The 
Plan also says that there is no deficiency for these services and alternate network providers were found. 
 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 drug testing (80307, G0480) provided on August 
4, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 26, 
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 Current Procedural Terminology (CPT) code 81479 (1 unit) remains 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. 
 
 
 
 
 
 
 
 
 
 We find that CPT code 81479 is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of an outpatient 
hospital. 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 May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 3, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you did not know there was a 
copayment for this service. The Plan denied your request. The Plan says the proper copayment was applied. 
 
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 per visit.  
 
  You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner services, including doctors office visits 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 a specialist visit provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit (99212) manual electrical stimulation 
(97032) therapeutic ultrasound (97035) provided August 18, 2021 to September 8, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that your doctor wanted you to receive 
services from this doctor instead of receiving services from a physical therapist. The Plan denied your request. 
The Plan says this service is not covered when obtained from a chiropractor. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for outpatient office visit (99212) manual electrical stimulation (97032) 
therapeutic ultrasound (97035) provided August 18, 2021 to September 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cabergoline tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that it is medically necessary to use this 
drug. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because 
this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D 
prescription drug benefits. 
 
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 cabergoline tablets.  
 Benefits for self-administered drug 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 22, 
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 Current Procedural Terminology (CPT) code 0242U (1 Unit) remains 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. 
 
We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a on campus 
outpatient hospital (POS 22). 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 June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode that could be 
delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary.  
 
 Our physician reviewer found the enrollee was recently hospitalized with acute hypoxic and hypercarbic 
respiratory failure, with congestive heart failure exacerbation. Chronic obstructive pulmonary disease (COPD) 
is mentioned in the record, but it is not listed as a diagnosis on admission, and the enrollee was not on COPD 
meds.  There are no pulmonary function tests to confirm the diagnosis. Obstructive sleep apnea (OSA) has not 
been excluded, and the enrollee likely has an element of obesity hypoventilation syndrome. A ventilator is not 
indicated or covered for those diagnoses. The enrollee may benefit from continuous positive airway pressure 
(CPAP) or bilateral positive airway pressure (BiPAP) at night, but Medicare does not cover a home ventilator 
when used as BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
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 does not meet 
criteria. 
 
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. The enrollee is 
not reasonably expected 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (J9271, J9355) provided September 3, 2021. 
 
You asked the Plan to pay for the injections. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these codes were billed without a required 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. 
 
 
 
 
 
 
  
We find that CPT codes J9271, & J9355 are not supported in the medical record. Specifically, these codes have 
a status of "K" and were not billed with a required Outpatient Prospective Payment System primary procedure. 
Based on this information, we decided that Medicare rules for coverage of the injections have not been met. 
Therefore, we decided that the Plan does not have to pay for injections (J9271, J9355) provided September 3, 
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 this is medically necessary. The Plan denied your 
request. The Plan says the plan states that the enrollee could receive care in another setting and the Plan could 
review alternate settings if requested such as a skilled nursing facility, outpatient setting or home health care. 
 
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 documentation does not support that the current complexity of the enrollee's 
nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a 
day/5 days a week, or 15 hours over 7 consecutive days, of therapy services. The documentation does not 
support that the enrollee is reasonably expected 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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 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 patient is a 72-year-old female who was admitted to the acute care hospital 
with acute respiratory failure and diabetic ketoacidosis related to pneumonia. She was treated with mechanical 
ventilation, antibiotics. The course was complicated by sepsis, deep vein thrombosis, thrombocytopenia, 
esophagitis, right above knee amputation related to ischemia. and ongoing respiratory distress. Trach and 
percutaneous endoscopic gastrostomy (PEG) placed. Basic wound care was required. Recent notes describe the 
patient as tolerating trach collar trials and tube feeds and diabetic ketoacidosis has resolved. The patient 
appears to be improving and more stable and should only require short-term additional acute care services that 
can be safely administered at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it 
would not be clinically advantageous at this time. Transfer to a lower level of care may be considered when 
treatment has completed. 
 
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 to the enrollee on July 20, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 0242U (1 Unit) remains 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. 
 
 
 
 
 
 
 
 
 
 
  
We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 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 July 20, 2021.
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 the enrollee does not have a need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care. Daily skilled services 
are not required. The enrollee does not require the services on an inpatient basis, only in a skilled nursing 
facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (96375, S0164) provided June 15, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the codes billed cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 96375 & S0164 is not supported in the medical record. Specifically, CPT 96375 was 
billed without a required modifier. Code S0164 is not recognized by Medicare for outpatient claims. Based on 
this information, we decided that Medicare rules for coverage of the outpatient services have not been met. 
Therefore, we decided that the Plan does not have to pay for outpatient services (96375, S0164) provided June 
15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 15, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 0242U (1 Unit) remains 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. 
 
 
 
 
 
 
 
 
 
  
 
We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 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 June 15, 2021.