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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had a fall and received a fracture. You 
also say that rehabilitation is needed for the enrollee to become mobile again. The Plan denied your request. 
The Plan says based on Medicare guidelines the inpatient rehabilitation facility services you are requesting do 
not meet the requirements for approval. 
 
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 
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit more from being admitted to an 
IRF. The Plan denied your request. The Plan says your rehabilitative care can be accomplished at the lower 
level of care where you are currently admitted in the 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 you are medically stable and do not need physical medicine and rehabilitation 
physician's close supervision 3 times per week (at a minimum) for ongoing management of any active or acute 
exacerbations of chronic medical conditions. No nursing needs are documented. While you may benefit from 
physical therapy and occupational therapy, your rehabilitation needs can be safely met in an alternate and low 
intensity 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab pathology services provided on July 13, 2022. 
 
You asked the Plan to pay for lab pathology services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab pathology services 
provided on July 13, 2022.
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 necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for admission to an IRF. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve salvage high intensity focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not show that the enrollee has recurrent cancer following radiation treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve salvage high intensity focused ultrasound (HIFU).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection provided on July 11, 2022. 
 
You asked the Plan to waive the copayment for injection. You say that this should be covered. 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 $350 
copayment for Outpatient surgery in a hospital outpatient facility. 
 
You have been asked to pay a $350 copayment for injection. This item/service falls within the Outpatient 
surgery in a hospital outpatient facility 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 injection provided on July 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the services are necessary. The Plan 
denied your request. The Plan says skilled nursing care is only covered for a total of 100 days per benefit 
period. The benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from September 21, 2022 to 
January 3, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the critical care services coded 99291 provided on March 23, 2022. 
 
You asked the Plan to pay for the critical care services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that evaluation and management codes are not covered for this 
specialty or provider type. 
 
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 states that evaluation and management codes are not covered for this 
specialty or provider type. The Plan did not provide Medicare rules to support this statement. No other 
documentation for denial rationale was provided. This means the Plan did not substantiate their denial. 
Therefore, we decided that the Plan has to pay for the critical care services coded 99291 provided on March 23, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for code 73552 billed for date of service August 7, 2022. 
 
You asked the Plan to pay for code 73552. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that this code exceeds the allowable units of service. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. 
 
We looked at the file and Medicare rules. Review of the file shows that one unit of service for code 73552 has 
been billed. The MUE for CPT code 73552 is 2. The MAI value for this code is 3. You billed 1 unit of this 
code, not exceeding the MUE. The Plan did not provide all the required evidence showing that there were 
excess units billed as 2 units are allowed and only 1 was billed. The Plan did not substantiate their denial. 
Based on this information, we decided that Medicare rules for coverage of code 73552 have been met. 
Therefore, we decided that the Plan has to pay for code 73552 billed for date of service August 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 May 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement in place which indicates that these tests 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 May 2, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services denied with code G provided to 
the enrollee from December 4, 2021, to December 13, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necesary. The Plan denied your 
request. The Plan says the remaining denied charges were denied for denial code G for unbundling. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 that the provider reported glucose 
monitoring; oxygen; evaluations; and solution separately. These billed services are nursing services and 
supplies and would not be billed separately from the daily charges. The provider reported Foley catheter 
insertion for date of service December 4, 2021.  However, medical record documents a foley catheter was 
placed during surgery on December 9, 2021, and documents on December 4, 2021 at "12/4/21 18:31 JZI7442 
Not Performed Place indwelling urinary catheter - Urologic-GU Surgery, etc; Not Performed Reason: 
ALREADY CHARTED".  This procedure cannot be verified as performed on the date of service reported. 
 
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 inpatient hospital services denied with code G provided to the enrollee from December 4, 2021, 
to December 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sleep study provided to the enrollee on June 8, 2022. 
  
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this service is not a Medicare benefit for the diagnoses listed on the claim. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records provided only show the polysomnography (PSG) report, which indicates diagnoses of 
snoring and periodic breathing. There is no medical encounter prior to the sleep study, with no complete sleep 
history, Epworth sleepiness score, or upper airway examination. The need for this study is therefore not 
established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a sleep study provided to the enrollee on June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve a group 3 power wheelchair. 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 follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 group 3 power wheelchair. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not 
have a neurological condition, myopathy or congenital spine condition which cause her functional impairment. 
 
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 group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural injection services. 
 
You asked the Plan to pre-approve epidural injection services. You say that the records provided support that 
the requested injection services were medically necessary. The Plan denied your request. The Plan says there is 
no evidence that the enrollee has tried 4 weeks of conservative therapy. 
 
The Plan follows Medicare rules. Medicare rules say that ESI services will be considered medically necessary 
when the inability to tolerate noninvasive conservative care or medical documentation of failure to respond to 
four weeks of noninvasive conservative care or acute herpes zoster refractory to conservative management 
where a four-week wait is not required. 
 
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 epidural injection services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the November 11, 
2022, office note orders physical therapy but there is no documentation of the effectiveness of those sessions. 
The requested injection services are not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural injection services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan. 
 
You asked the Plan to pre-approve Zioptan. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Zioptan.  
 
Benefits for Zioptan 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve podiatry services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
podiatry services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary and should 
be covered. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on January 26, 2022.