Persius/hicric huggingface dataset:
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 the enrollee is getting weaker as time passes. 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 the enrollees 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the REVO click socket. 
 
You asked the Plan to pre-approve the REVO click socket. You say that the records provided support the 
medical necessity of the item which remains in dispute. The Plan denied your request. The Plan says the 
requested socket does not have Food and Drug Administration (FDA) approval. The Plan says that his item is 
experimental and has not been found to be safe and effective. The Plan says that a standard socket has already 
been approved. 
 
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 REVO click socket. Our reviewer says that the REVO click socket is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the REVO Click Socket exceeds the patient's medical needs. Our physician reviewer 
found that this device is not proven safe and effective 
 
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 REVO click socket have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the REVO click socket.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria for admission to a LTACH 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be gradually improving but still somewhat unstable and 
requires additional acute care services that can safely be provided at the current facility until more stable for 
transfer. 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: 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 your husband is eager to participate in therapy. The 
Plan denied your request. The Plan says that the coverage criteria for admission to an IRF has not been met. 
 
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 enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports 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. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spine fusion and lumbar decompression coded 
as 22842, 22614, 22612 and 63042. 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee continues to lose function 
and ability to perform activities of daily living. The Plan denied your request. The Plan says based on the 
clinical information received, the request 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has had a previous lumbar laminectomy. There is no fracture, instability, 
or severe neurologic deficit. The criteria for spine surgery were not met. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spine fusion and lumbar decompression coded as 22842, 22614, 22612 
and 63042.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the coinsurance for an oxygen concentrator provided on June 
30, 2022.  
 
You asked the Plan to adjust the coinsurance for an oxygen concentrator. You say that since June, without 
informing you, your coinsurance was increased. 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 20% 
coinsurance for durable medical equipment.  You have been asked to pay $22.92 for an oxygen concentrator ($114.60 x 20% = $22.92). This item/service 
falls within the durable medical equipment 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 adjust the coinsurance 
for an oxygen concentrator provided on June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab tests provided on July 5, 2022, to July 
14, 2022. 
 
You asked the Plan to waive the copayment for lab tests. You say that you are disputing the share cost. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $10 copayment for lab tests. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for lab tests provided on July 5, 2022, to July 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says it cannot be 
determined how the enrollee came to the servicing provider. 
 
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 the services have been met. The 
submitted documentation does not contain records from the non-contract provider for the date of service in 
question. Therefore, we decided that the Plan does not have to pay for the services provided on February 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a vision care visit provided on April 7, 
2022. 
 
You asked the Plan to waive the copayment for a vision care visit. You say that you disagree with the 
copayment. 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 $30 
copayment for Vision care.  
 
You have been asked to pay a $30 copayment for a vision care visit. This item/service falls within the Vision 
care 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 vision care visit provided on 
April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64484 billed for date of service December 
16, 2021. 
 
You asked the Plan to pay for procedure code 64484. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 64484 is bundled into payment for code 27096.  
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 64484 
is a column II code to column I code 27096. 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 64484 billed for date of service December 16, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 28, 2021, 
to September 30, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
claim was submitted correctly and is supported in the medical record. The Plan denied your request. The Plan 
says the diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in the medical record; 
therefore, the DRG billed on this claim is inappropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with acute respiratory failure with hypoxia (J96.01). 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 hospital services at the DRG 
originally billed. Our reviewer says that this diagnosis is not supported in the medical record. Our physician 
reviewer found the documentation provided does not include evidence that the enrollee required high flow 
oxygen, bi-level positive airway pressure (BiPAP), and that the enrollee was in persistent distress with 
treatment. Therefore, there is insufficient support for the use of acute respiratory failure with hypoxia as a 
diagnosis for this patient on this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 28, 2021, to September 30, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments - dispensed for home use (D9630) 
provided on July 22, 2022. 
 
You asked the Plan to pay for the drugs or medicaments - dispensed for home use. You say that you cannot 
afford the cost of this service. The Plan denied your request. The Plan says this service is not covered under 
your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the drugs 
or medicaments - dispensed for home use (D9630) provided on July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided 
from April 25, 2022, to April 28, 2022. 
 
You asked the Plan to pay for the subsequent 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 separately payable. 
 
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 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this service was billed 
within the global surgical package of code 33418 (transcatheter mitral valve repair, percutaneous approach, 
including transseptal puncture when performed; initial prosthesis) provided on April 14, 2022. This means that 
code 99232 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have 
to pay for the subsequent hospital care services coded 99232 provided from April 25, 2022, to April 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
(72141). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says that you do not meet criteria for coverage of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that in this case, the record 
provided does not indicate that you have any red flag symptoms or other complaints that relate to cervical spine 
disease. The record indicates that you had a normal neurological examination. The record does not include 
plain x-rays that support the medical necessity for the requested test. The requested service is not medically 
necessary and reasonable for the diagnosis and treatment for your clinical condition at this time. The elements 
of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the cervical spine (72141).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria for admission to an IRF has not been met. 
 
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 enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports 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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 14, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on June 14, 2022, by an out-
of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided April 5, 2022, to June 1, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim was submitted with an invalid type of bill. 
 
The Plan follows Medicare rules. The rules say that the claim and NOA for home health services must have 
correct information. 
 
Review of the file shows that this claim was billed with type of bill 323 and 324. The correct type of bill for 
home health is 329. As this claim was billed with an invalid type of bill, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services provided April 5, 2022, 
to June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214). You 
say that you want to appeal. The Plan denied your request. The Plan says these services are not covered under 
your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110) and a partial lower denture (D5214).