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 you have Parkinson's Disease and dementia and 
needs to go to Acute Rehabilitation to regain strength and ability to walk independently. The Plan denied your 
request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. 
Your ongoing skilled therapy and nursing needs can be provided at a lower level of care such as at a Skilled 
Nursing Facility, on an intermittent basis at home with home health care, or in a long-term care setting. 
 
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 enrollee does not require the intensity of services provided at 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation (codes 99203 and 99213) and bilateral 
venous ultrasound (codes 93970 and 93971). 
 
You asked the Plan to pre-approve an evaluation and bilateral venous ultrasound. The Plan denied your request. 
The Plan says the medical records do not show three (3) months of conservative therapy with symptoms 
impacting the enrollee's activities of daily living, and there is no evidence of testing to confirm diagnosis 
documenting venous valvular incompetence. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
 
  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 evaluation and bilateral venous 
ultrasound. Our reviewer says that the enrollee does not meet the coverage criteria for an evaluation and 
bilateral venous ultrasound. Our physician reviewer found the enrollee has swelling in their legs noted on 
January 23, 2023, by their treating physician who referred them to a vein specialist for a bilateral venous 
ultrasound and consultation. The enrollee was diagnosed with venous insufficiency, chronic, peripheral. 
However, our reviewer found that the provided records did not clearly show supportive objective confirmation 
testing of the enrollee's diagnosis. Also, the records did not clearly show the enrollee having completed and 
failed a full trial of conservative therapy to need a specialist/surgeon consultation. Our physician reviewer also 
found that due to lack of confirmation testing and completion of conservative care, this request does not meet 
the coverage criteria. 
 
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 evaluation and bilateral venous ultrasound have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an evaluation (codes 99203 and 99213) and bilateral venous 
ultrasound (codes 93970 and 93971).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from December 29, 2021, to 
December 30, 2021. 
 
You asked the Plan to pay for the inpatient stay. You say that you would like this claim to be reviewed and 
reprocessed. The Plan denied your request. The Plan says inpatient medical necessity is not demonstrated, and 
transition to outpatient management within the first 48 hours of admission is also noted. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient stay. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from December 29, 2021, to December 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 24, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the claim has met Medicare criteria for 
inpatient admission and was provided in accordance with the Medicare guidelines. The Plan denied your 
request. The Plan says the records submitted do not support the medical necessity for inpatient services. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show at the time of inpatient admission that the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on April 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone (code G2067) provided on 
October 17, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone. You say that you have been enrolled 
in the Medicare program to provide Opioid Treatment Program (OTP) services since January 01, 2020. The 
Plan denied your request. The Plan says that an individual provider cannot bill for OTP services. 
 
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 OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for 
medication assisted treatment, methadone (code G2067) provided on October 17, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator (FES), transcutaneous 
stimulation of nerve and/or muscle groups, any type (E0770). 
 
You asked the Plan to pre-approve an electrical stimulator. You say that the enrollee has right facial weakness 
following surgery. You say that the enrollee has had therapy with electrical stimulation which has helped. You 
also say that it would be prudent for the enrollee to have this device to continue the therapy. The Plan denied 
your request. The Plan says it is unclear whether the nerve supply to the muscle is intact. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of neuromuscular electrical stimulation 
(NMES) to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle 
is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse 
atrophy. 
 
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 electrical stimulator. Our reviewer 
says that the requested electrical stimulator is not medically necessary. Our physician reviewer found there is 
no documentation that the functional electrical stimulator at issue in this case meets all Medicare criteria for 
medically reasonable and necessary and safe and effective for the enrollee. The reviewer found that the 
provided documentation does not document nerve supply to the facial muscle is intact. Therefore, the reviewer 
found that the requested device is not 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 an electrical stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a functional electrical stimulator (FES), transcutaneous stimulation of nerve 
and/or muscle groups, any type (E0770).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography perfusion analysis (CTP) provided 
on October 14, 2022, billed with code 0042T. 
 
You asked the Plan to pay for the CTP. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services are not a Medicare covered benefit for the diagnosis listed on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we find that coverage for CTP is allowed 
when the pre-CTP criteria from either the DAWN or DEFUSE 3 trials are met. The provider did not include 
records from the ordering physician to show that these criteria were met. Only the imaging report was 
submitted, which does not provide the information needed. Specifically, there is no documentation of pre-
stroke baseline or the length of time since symptoms began. As such, the criteria for coverage of the CTP have 
not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography perfusion 
analysis (CTP) provided on October 14, 2022, billed with code 0042T.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services (99285) provided on August 
10, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 procedure code 99285. Our reviewer says 
that the medical records do not support the billing of code 99285. Our reviewer found the documentation 
indicates that the enrollee was with a history of hypertension (HTN), Atrial fibrillation, hyperlipidemia (HLD), 
Depression and gastroesophageal reflux disease (GERD) who presented to the emergency department on 
August 10, 2022, after reporting of an abnormal lab- Hemoglobin 6. The review has determined that Current 
Procedural Terminology (CPT) code 99285 (1 Unit) was not supported. This emergency department evaluation 
and management code requires a comprehensive history, a comprehensive examination and medical decision 
making of high complexity. In this case, the medical records submitted did not support medical decision 
making of high complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency room services (99285) provided on August 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on February 17, 
2022. 
 
You asked the Plan to pay for the paramedic intercept 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 rules say that paramedic intercept services must also be billed with an appropriate mileage code and 
modifier. 
 
The paramedic intercept services at issue in this appeal were not billed with an appropriate mileage and 
modifier. This means the services were billed incorrectly. Therefore, we decided that the Plan does not have to 
pay for the paramedic intercept services provided on February 17, 2022.
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 is stable and safe for 
discharge to an LTACH for continuation of their acute care needs. The Plan denied your request. The Plan says 
an LTACH admission is not medically necessary, and the enrollee can receive the care they need 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 improving and only requires short-term acute care at the current 
facility until they are more stable. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99291 provided on 
September 26, 2022. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
support that the enrollee was inpatient status for this date of service. Based on this information, we decided that 
Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we decided that 
the Plan does not have to pay for the initial hospital care services coded 99291 provided on September 26, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a special treatment procedure-(total body irradiation, hemibody 
radiation, per oral or endocavitary irradiation) representing procedure code 77470 provided on October 13, 
2022. 
 
You asked the Plan to pay for a special radiation treatment. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that that the procedure denied due to related procedure not being 
paid. 
 
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. though the denial rationale is that payment cannot be made as a related 
procedure was not paid, there is no evidence provided to show either that a related procedure occurred, nor that 
it was denied. As such, the denial of payment is not substantiated. Therefore, we decided that the Plan has to 
pay for a special treatment procedure-(total body irradiation, hemibody radiation, per oral or endocavitary 
irradiation) representing procedure code 77470 provided on October 13, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary and the enrollee is not in a clinical trial. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling data to suggest that proton beam therapy is superior to - or 
beneficial than - intensity modulated/image-guided radiation therapy (IMRT/IGRT). The generally accepted 
standard of care for prostate cancer is to only offer proton therapy in clinical trials and to not routinely offer it 
to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing is covered by Medicare and this claim 
should be paid. 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 September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transplant related lodging, meals and transportation provided 
from September 7, 2021 to August 31, 2022. 
 
You asked the Plan to pay for transplant related lodging, meals and transportation. You say that you are 
disabled so these visits required someone to transport and accompany you as you are not able to do this on your 
own on such a long commute. The Plan denied your request. The Plan says a letterhead invoice was not 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of transplant related lodging, meals and 
transportation have been met. A letterhead invoice was not provided. Therefore, we decided that the Plan does 
not have to pay for transplant related lodging, meals and transportation provided from September 7, 2021 to 
August 31, 2022.