Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy visits. 
 
You asked the Plan to pay for the visits. You say that this is medically necessary. The Plan denied your request. 
The Plan says the records do not support approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
The requested visits are not medically reasonable or necessary. Our physician reviewer found that there is 
limited clinical history regarding the patients current level of function and limited physical examination 
findings documenting his motor strength and range of motion. Without this information, it is difficult to 
determine if the requested physical therapy is appropriate and medically 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pay for physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services so you can improve your heart 
and walk again. The Plan denied your request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
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 the enrollee needs daily lab management 
and treatment plan adjustments based on abnormal lab results. You say that enrollee's needs aggressive wound 
care management. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee's services they needs could be provided in another setting. 
 
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 is more stable and should only require short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services are not medically necessary. Our physician reviewer found the records show that you have a 
mobility deficit but there is no documentation of an evaluation of your ability to operate a power scooter safely. 
There is no evaluation of your home to see if it is able to accommodate the power scooter. Furthermore, the 
documentation states you would like the power scooter to get around the grocery store. The documentation 
does not support that the power scooter is reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Furthermore, the file shows that the power 
scooter is being requested for use outside of the home and is not covered for this use. Therefore, we decided 
that the Plan does not have to pre-approve a power scooter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography/computed tomography 
(PET/CT) of the brain. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the guidelines for 
coverage of PET/CT in the face of cognitive decline specify that a potential diagnosis of FTD be present in 
order to approve the request. Specifically, Medicare requires that FTD vs. AD is the differential diagnosis and 
the PET/CT will be used to differentiate the two possibilities.  There are no clinical factors in this particular 
case to bring the possibility of FTD into the differential and no mention of that possibility in the submitted 
records. Absent fulfilling this specific criterion of Medicare, the examination should be denied. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve positron emission tomography/computed tomography (PET/CT) of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot feature and an electronic knee for a 
prosthetic leg. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for a K3 knee and foot does not meet the Medicare criteria as reasonable and 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the Ottobock Kenevo microprocessor knee (L5848, L5845, L5856, L5828) exceeds the patient's 
medical needs and does not meet Medicare medically necessary criteria. The requested microprocessor knee 
has features such as intuitive use of a stationary indoor bicycle, adjustments from a smartphone with the 
Cockpit app, and convenience features of charging without removing the foam cover. The physician 
documentation does not reveal that the patient requires a microprocessor knee K3 knee as a scooter was 
approved and patient uses an assistive device. Also, the requested Kenevo knee has deluxe features which are 
not medically necessary for the patient. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an advanced foot feature and an electronic knee for a prosthetic leg.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for critical care services (99291) provided on April 29, 2022, and April 30, 
2022. 
 
You asked the Plan to pay for critical care. You say that this claim was denied in error. The Plan denied your 
request. The Plan says that this service has an MAI of 2 and an MUE of 1. Two units of this service were 
billed, exceeding the MUE. Therefore, this claim is denied. 
 
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. Specifically, the Plan denied this service because two units of 99291 were billed 
on one claim. However, each unit was billed for a different date of service. An MAI of 2 applies to a single 
date of service at a time. Based on the records provided, only one unit of 99291 has been billed per date of 
service, which means that the MUE has not been exceeded in this case. Therefore, we decided that the Plan has 
to pay for critical care services (99291) provided on April 29, 2022, and April 30, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve daily home health skilled nursing visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request will be reduced from daily to weekly visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 visits. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that daily skilled 
nurse visits are not shown to be medically necessary or reasonable. Daily skilled nurse visits do not meet the 
definition of intermittent. As such, the requested services are not medically necessary, reasonable or coverable. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve daily home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9088 billed for date of service June 16, 
2022. 
 
You asked the Plan to pay for procedure code S9088. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid 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 procedure code. 
 
We find that procedure code S9088 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9088 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9088 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9088 billed for date of service June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing (83789) billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for validity testing. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing (83789) billed for date of service April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on April 06, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you want to appeal the 
amount be charged. 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. The provider billed in the 
amount of $303 and the allowed amount is $140.44. This is less than the copayment amount. Therefore, results 
in the total cost sharing amount of $140.44. 
 
 
 You have been asked to pay a $140.44 copayment, which is less than the copayment for outpatient services. 
This item/service falls within the Outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 outpatient services on April 06, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy administration services provided to the 
enrollee on April 8, 2022. 
 
You asked the Plan to pay for the services. You say that the expedient review and resolution of this claim is 
appreciated. The Plan denied your request. The Plan says the code was denied as there is a more appropriate 
code to use. 
 
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 96413 is "Chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug." 
 
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 medical records do not 
support the use of CPT 96413. There is no documentation of time limits in the record, which is needed to 
accurately document this procedure code.  
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 chemotherapy administration services provided to the enrollee on April 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for dates of service March 4, 
2022, to March 15, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the billed code is invalid 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 procedure code. 
 
We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for dates of service March 4, 2022, to March 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63048 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 63048. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 63048 is bundled into payment for code 22633. 
 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 63048 
is a column II code to column I code 22633. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 63048 billed for date of service July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
February 9, 2022. 
 You asked the Plan to pay for the screening services. You say that you understand that procedure code 81479 is 
an unlisted procedure code, but this is the only procedure code you can use for this test. The Plan denied your 
request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for 
the health of the patient are not a benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the screening services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the unlisted molecular pathology procedure (81479) provided February 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
January 1, 2021, to January 4, 2021. 
 
You asked the Plan to pay for the SNF 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 follows Medicare rules. Medicare rules say that providers must report services correctly 
 
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 SNF services. Our reviewer says that the 
services are not payable as billed. Our physician reviewer found the enrollee was admitted to the skilled facility 
on December 29, 2020 and had a 5-day MDS assessment ARD of January 3, 2021, which is day six and within 
the required timeframe. The documentation provided did not support the coding of the MDS Item: O0100M2: 
Isolation for active infectious disease (does not include standard precautions) post admit. Therefore, the 
services were not payable as billed. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from January 1, 2021, to January 4, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99291 billed for date of service February 14, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the Plan has denied because claims submitted where the unit of 
service exceeds the MUE value cannot be paid when the MAI value is 2. The MUE for CPT code 99291 is 1. 
The Plan has not documented that the MUE has been exceeded in this case. It is the Plan's responsibility to 
substantiate its denial with evidence. In this case, the Plan has not substantiated its denial, so we must find in 
your favor. Therefore, we decided that the Plan has to pay for procedure code 99291 billed for date of service 
February 14, 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.