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 would like reconsideration because the 
requested IRF services are medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the IRF services. 
 
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural injections. 
 
You asked the Plan to pre-approve transforaminal epidurals. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the Plan already approved two levels and no more than two injections can be done during a single 
setting. 
 
The Plan follows Medicare rules. Medicare rules state that no more than two transforaminal epidural injections 
may be performed in a single setting. 
 
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 transforaminal epidurals. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested transforaminal epidural injections 
beyond what was already approved by the Plan. Our physician reviewer found only one level bilaterally or two 
levels on one side is considered medically reasonable and necessary, so this request exceeds utilization 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 transforaminal epidurals have not been met. Therefore, we decided that the Plan 
does not have to pre-approve transforaminal epidural injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the continued SNF care. You say that you would like reconsideration 
because the requested SNF care is medically necessary. The Plan denied your request. The Plan says you do 
not meet Medicare criteria for coverage of the continued care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
 
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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continued Skilled Nursing Facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testosterone gel. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not 
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve testosterone gel.  
 Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the destruction by neurolytic agent, of a 
paravertebral facet joint nerve(s), with imaging guidance (64635) provided on September 30, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $345 
copayment for services billed by a freestanding ambulatory surgery center.  
 
You have been asked to pay a $345 copayment for the Medicare-covered surgery provided by a freestanding 
ambulatory surgery center.  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 the destruction by neurolytic agent, of a 
paravertebral facet joint nerve(s), with imaging guidance (64635) provided on September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds criteria for an 
LTACH admission. The Plan denied your request. The Plan says criteria for admission to the LTACH have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and was treated for pain. The enrollee was at a contact guard assist level for functional 
mobility including gait to 75 feet with a rolling walker. The enrollee does not require skilled nursing or therapy 
services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the beneficiary is a 96-year-old male with 
metabolic encephalopathy, urinary tract infection, and constipation. In this case, there are no identifiable skilled 
nursing service needs and no identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Monitor testing provided on August 13, 2021. 
 
You asked the Plan to pay for the CxBladder Monitor testing. You say that this testing is necessary to allow 
physicians to stratify patient risk for developing malignancy. The Plan denied your request. The Plan says this 
is not a clinically validated test. 
 
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 CxBladder Monitor testing have 
been met. Specifically, no clinical records for this enrollee have been submitted for review. The file only 
contains literature to support that the test is clinically useful in general, but nothing to support that it is 
medically necessary for this enrollee. Without medical records, it cannot be confirmed that Medicare coverage 
criteria have been met. Therefore, we decided that the Plan does not have to pay for the CxBladder Monitor 
testing provided on August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 27, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code  is not supported in the medical record. Specifically, the place of service on the CMS-
1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place 
of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office 
(POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee 
on May 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdominal ultrasound (76700) provided 
on October 15, 2021. 
 
You asked the Plan to waive the copayment for an abdominal ultrasound. You say that your copayment is 
normally lower. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $115 
copayment for Medicare-covered radiological diagnostic services, not including X-rays or diagnostic 
mammograms.  
 
 You have been asked to pay $103.43 for an abdominal ultrasound. An abdominal ultrasound falls within the 
"Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you 
have been asked to pay less than or equal to the full and 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 an abdominal ultrasound (76700) provided on 
October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 81479) provided to the 
enrollee on May 9, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 
 
 
  
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of an on-campus 
outpatient hospital (POS 22). Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
(procedure code 81479) provided to the enrollee on May 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 24, 
2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that you chose to opt out of Medicare because 
Original Medicare does not provide dental benefits. You would like the Plan to reconsider payment because 
you would have opted back in if you knew it would affect your patients. The Plan denied your request. The 
Plan says dental care is not covered when it is performed by providers who have chosen to opt-out of Original 
Medicare. 
 
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. The Plan requires 
supplemental dental care be performed by providers who have not opted out of Original Medicare. We looked at the file and the Plans rules. The provider in this case does not participate in Original Medicare. 
Based on this information, we decided that the Plans rules for coverage of supplemental dental services have 
not been met. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
(D4910) provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Fluciclovine f-18, diagnostic injection 
(A9588) provided on March 24, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the medical supply provided. 
 
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 20% 
coinsurance for each Medicare-covered medical supply. Supplies for which an appropriate separate charge is 
made by providers (such as, chemical agents used in certain diagnostic procedures) are subject to cost-sharing.  
You have been asked to pay $913.14 (Medicare allowed amount of $4,565.70 x 20% coinsurance) for the 
Medicare-covered medical supply provided. 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 coinsurance for the 
Fluciclovine f-18, diagnostic injection (A9588) provided on March 24, 2021.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the definitive drug testing (G0483). We decided that the Plan does not 
have to pay for the conveyance of specimen from office to lab (99000).  
 
You asked the Plan to pay for the definitive drug testing (G0483). You say that these services should be paid. 
The Plan says that code G0483 is not appealable, and code 99000 cannot be separately paid. 
 
We decided that the Plan has to pay for the definitive drug testing (G0483).  
 
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 did not gather and forward a valid rationale for the denial of code G0483. The code was denied on 
October 1, 2021, for requested information not being received. That such information was received as an 
appeal request would not exempt the code from an appeal determination. Since the Plan forfeited the 
opportunity to provide a valid denial rationale, we find that the denial is not substantiated. Therefore, we 
decided that the Plan has to pay for the definitive drug testing (G0483).  
 
We also decided that the Plan does not have to pay for the conveyance of specimen from office to lab 
(99000). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99000 has a status indicator of B on the Physician Fee Schedule. This means that payment for this 
service is bundled into payment for other services. Therefore, we decided that the Plan does not have to pay for 
the conveyance of specimen from office to lab (99000). 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided to the enrollee on 
October 15, 2020. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim was submitted past the allowed twelve month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until October 20, 2021. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for emergency room services provided to the enrollee on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 9, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the ordering provider confirmed they did not order the denied tests. 
 
The Plan must follow Medicare rules. Medicare rules say that there must be a valid order to cover laboratory 
tests. 
 
It does not appear that the treating physician/ordering provider actually ordered the denied laboratory services. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on 
July 9, 2021.