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 the enrollee requires IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for 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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy. It is unlikely that he will make a significant functional progress in a reasonable period of time in 
an IRF having reached maximal potential in the skilled nursing facility and being discharged by physical 
therapy and occupational therapy. An IRF admission is not medically necessary based on lack of medical 
complexity, and lack of acute rehabilitation nursing needs and poor rehabilitation potential. The documentation 
does not support the necessity for admission to 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for an arthrocentesis and a Hyaluronan 
injection provided on October 1, 2021. 
 
You asked the Plan to waive the cost sharing for an arthrocentesis and a Hyaluronan injection. You say that at 
the time of the procedure you were told you owed $93.67 which you paid. You also say that now you are 
receiving a bill for $311.11. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $325 copayment for in-network outpatient surgery at an outpatient hospital. Your contract with the Plan also clearly 
says that you must pay 20% coinsurance for in-network Part B drugs. 
 
You have been asked to pay the allowed amount of $253.65, which is less than the $325 copayment for an 
arthrocentesis. An arthrocentesis falls within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. You have also been asked to pay 
$151.13, which is 20% of the allowed amount for a Hyaluronan injection ($755.64 allowed amount x 20% 
coinsurance = $151.13). A Hyaluronan injection falls within the Medicare Part B Prescription Drugs benefit 
category. You have been asked to pay a total of $404.78 ($253.65 copayment + $151.13 coinsurance= 
$404.78). 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 cost sharing for an arthrocentesis and a Hyaluronan injection 
provided on October 1, 2021.
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 the enrollee needs to receive physical therapy at an 
IRF. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also found that 
there is not a reasonable expectation that this patient 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on May 
9, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you were told to ignore 
the bill, and it would be taken care of by the Plan. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $200 
copayment for ambulance services.  
 
You have been asked to pay a $200 copayment for ambulance transportation. Ambulance transportation falls 
within the Ambulance Services 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 ambulance transportation provided on May 9, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says that this drug is experimental. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
drug is medically necessary. Our physician reviewer found this drug is FDA approved for the members 
diagnosis and the compendia reports this drug is 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda (J9271).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for photopheresis (36522). 
 
You asked the Plan to pay for photopheresis. You say that you have been underpaid for the services rendered. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 photopheresis (36522) have been met. 
Specifically, the medical records provided do not address the coverage criteria listed the applicable NCD for 
photopheresis services. Therefore, we decided that the Plan does not have to pay for photopheresis (36522).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair (omalizumab) injection.
You asked the Plan to pre-approve Xolair. You say that the requested injection is medically necessary. The Plan denied your request. The Plan says the requested injection is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Xolair. Our reviewer says that the requested drug, Xolair, is not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the Xolair meets health plan and Medicare criteria for medically reasonable and necessary for the enrollee. The provided records do not clearly document that the enrollee has had persistent hives with itching for at least 8 consecutive weeks despite an adequate trial of H1-antihistamines as required by the health plan's prior authorization criteria. The provided records report an emergency room visit on December 25, 2021 for "some swelling on his lips and face" and he was "splotchy on his face and neck with red spots." The documentation indicates that by December 28, 2021 no hives or itching were reported and no abnormal physical examination findings were documented. Therefore, the reviewer found that the requested drug is not medically reasonable or 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 Xolair have not been met. Specifically, the file does not indicate that the enrollee has had persistent hives with itching for at least 8 consecutive weeks despite an adequate trial of H1-antihistamines. Therefore, we decided that the Plan does not have to pre-approve Xolair (omalizumab) injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0242U) provided September 1, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 0242U is not supported in the medical record. Specifically, the place of service listed on the claim form (81, lab) does not match the place of service detailed in the records (22, outpatient setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (0242U) provided September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
(83789) provided on July 13, 2021. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry. You say that you would 
like reconsideration based on the records submitted. The Plan denied your request.  The Plan says providers performing validity testing on urine specimens utilized for drug testing should not 
separately bill the validity testing. 
 
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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
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 mass spectrometry and tandem mass spectrometry. Our 
reviewer says that CPT code 83789 does not meet criteria for billing or reimbursement consideration. Our 
reviewer found in this case, services reported does not meet Medicare criteria, as an additional test was billed 
to test a urine specimen to confirm validity. Providers performing validity testing on urine specimens utilized 
for drug testing shall not separately bill the validity testing. 
 
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 mass spectrometry and tandem mass spectrometry have not been met. 
Therefore, we decided that the Plan does not have to pay for the mass spectrometry and tandem mass 
spectrometry (83789) provided on July 13, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services (99285) provided on June 17, 2021. 
 
You asked the Plan to pay for the emergency room services (99285). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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. In this case, the Plan denied payment for code 99285 provided on June 17, 2021, 
stating that the records only support one unit and the provider billed two units. However, the Plan provided two 
claims that were both denied for payment. The Plan has not shown that they have paid for the emergency room 
services (99285) provided on June 17, 2021, by this provider. Therefore, we decided that the Plan has to pay 
for the emergency room services (99285) provided on June 17, 2021.  
 
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 additional power wheelchair accessories (E2311, 
E2313, E2377) for the enrollee. 
 You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says upper limb strength and function are adequate for the enrollee to be able to control 
the power options using their own switches which are included in the allowance of these power options. 
 
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 accessories. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, 
etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic 
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an 
attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the patient 
does not need to control the power options through a joystick. The enrollee's right upper extremity strength and 
function support that the enrollee can control any power options through their own switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this device is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the 
requested bi-level positive airway pressure (BiPAP) therapy with backup rate in average volume-assured 
pressure support (AVAPS) mode is available on BiPAP devices and would meet the enrollee's needs. The Plan 
also says that Medicare does not cover ventilators used in this way. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators are not covered when used to provide 
positive airway pressure therapy, regardless of the underlying medical condition.  
 
We looked at the file and Medicare rules. The requested ventilator is not covered by Medicare for this purpose. 
The Plan says that a bi-level positive airway pressure (BiPAP) device may meet the enrollees needs instead. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example, a skilled nursing 
facility or home with continued home health 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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. documentation does not support that the enrollee requires at least 3 hours a day /5 day a 
week, or 15 hours over 7 consecutive days, of therapy services. Therapy services can be provided at a lower 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81210, 81235, 81275, 81276, 81295, 81298, 
81301, 81317, 81401, 81194, 81309) provided July 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 codes 81210, 81235, 81275, 81276, 81295, 81298, 81301, 81317, 81401, 81194, & 81309 
are not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) 
does not match the place of service detailed in the records (11, office setting). Additionally, multiple unbundled 
codes were billed for a single genetic testing panel. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (81210, 81235, 81275, 81276, 81295, 81298, 81301, 81317, 81401, 81194, 81309) provided July 
24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided September 28, 2021. 
 You asked the Plan to pay for the radiology services. You say that the radiology services were medically 
necessary. The Plan denied your request. The Plan says the billed code shares a bundled relationship with 
another code 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. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 radiology services (70450) provided September 28, 2021.