Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the most appropriate 
setting to improve the enrollee's condition. The Plan denied your request. The Plan says the enrollee is 
currently receiving medically necessary acute and/or critical care. The enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital, and there are no issues for which the 
LTACH may offer a therapeutic advantage. 
 
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 improving somewhat but is still unstable for transfer as 
they are still dependent on a dobhoff feeding tube. They should only require short-term additional acute care 
services that can safely be administered at the current facility until more appropriate for a lower level of care. 
The enrollee does not require services at the LTACH that are not already available at the current facility. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary as the enrollee does not have stable feeding status 
and as it would not be clinically advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for urgent care visits January 2, 2022, to April 
20, 2022. 
 
You asked the Plan to waive the copayments for urgent care visits. You say that you were not informed at the 
time of service that there would be a copayment. The Plan denied your request. The Plan says the cost share 
was applied 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 $45 
copayment for each covered urgently need service.  
 
 
 
 
 
 
 You have been asked to pay $450 ($45/visit x 10 visits) for urgent care visits. Urgent care visits fall within the 
Urgently Needed 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 copayments for urgent care 
visits January 2, 2022, to April 20, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional pair of eyeglasses. 
 
You asked the Plan to pre-approve an additional pair of eyeglasses. You say that the requested additional eye 
wear is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when [Insert why/when the plan covers routine vision]. 
 
We looked at the file and the Plan's rules. You have exceeded your benefit limit. Based on this information, we 
decided that the Plan's rules for coverage of an additional pair of eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an additional pair of eyeglasses.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 81015 and 82947 billed for date of service 
June 5, 2020. 
 
You asked the Plan to pay for procedure codes 81015 and 82947. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 81015 is bundled into payment for code 
81000. The Plan also says that payment for code 82947 is bundled into payment for code 80053. 
 
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 81015 
is a column II code to column I code 81000. This claim has not been billed with an appropriate modifier to 
bypass the edit. In this case, we have confirmed that code 82947 is a column II code to column I code 80053 
with a modifier indicator of 0. The column II code is therefore not payable. 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 codes 81015 and 82947 billed for date of service June 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81455 provided on April 12, 
2022. 
 
You asked the Plan to pay for the laboratory 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 by the documentation. 
 
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 81455 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on March 31, 2022. The billed date of service of April 12, 2022 is not 
supported by the documentation. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met.  
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81455 provided on 
April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on February 23, 
2022. 
 
  You asked the Plan to pay for moderate sedation services (99153). You say that the enrollee had multiple 
exams on this date of service and the attached reports support the level of service. You say that the claim 
should be reconsidered for processing. The Plan denied your request. The Plan says procedure code 37244, 
36251, 76937 and 99152 have been approved. The Plan also says procedure code 99153 remains denied as the 
provider did not bill as required by Medicare coding regulations. 
 
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 99153 is not supported in the medical record. Specifically, this service must be 
furnished directly by the hospital or billed through the hospital when provided to hospital inpatients. Based on 
this information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) 
provided on February 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot get up by yourself and your mobility is 
limited. You need to get to your prior level of functioning. The Plan denied your request. The Plan says the 
records do not show that the enrollee needs to be seen by a rehabilitation doctor at least 3 times a week, or that 
they need 3 hours of therapy a day at least 5 days per week, or that the enrollee needs an intensive team 
approach to their care. The services the enrollee needs can be provided safely in other settings like a skilled 
nursing facility, home with home health services or home with outpatient therapy. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for chest pain and had coronary artery bypass grafting. Medical problems are stable. 
There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 
 
There is not a reasonable expectation that this enrollee 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 the IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing frame/table. 
 
You asked the Plan to pre-approve a stand frame/table. You say that the records provided support the need for 
the requested item. The Plan denied your request. The Plan says the requested item is not covered under the 
enrollee's benefit package. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a standing frame/table.
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 these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee's current medical needs are being met in the current 
acute 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 17, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were told by the facility that 
you did not owe a copayment. The Plan denied your request. The Plan says you have been charged the correct 
copayment 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 $50 
copayment for Medicare covered diagnostic radiology services received in a provider's office or freestanding 
facility. 
 
You have been asked to pay a $50 copayment for an ultrasound. The ultrasound 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 an ultrasound provided on March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2022 billed with 
codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 0031U, 0032U, 0033U, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 1, 2022 billed with codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 0031U, 0032U, 
0033U, and 81238.
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 would greatly benefit from IRF care. 
The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. The 
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: 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 IRF care is needed for more therapy to become more 
independent. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF 
services 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 that the complexity of the enrollees nursing, medical and rehabilitation needs do not require an IRF stay with an interdisciplinary approach to rehabilitation care. The enrollees medical status does 
not require intensive physician and nursing oversight in an IRF. While the enrollee may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that the 
enrollee requires this therapy on an intensive IRF level. The enrollee has been educated in safe swallowing 
techniques. The enrollees functional needs can be met 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 1, 
2022.  
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. In this 
case, we have confirmed that code 83789 is a column II code to column I code G0481. While this code was 
billed with the -59 modifier, the medical records provided do not show that the service billed with the -59 
modifier is a distinct procedural service. 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 83789 billed for date of 
service April 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667, 
E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you feel this is a needed 
service, not a wanted service. You say the swelling in your legs, knees and ankles are red and hot to the touch. 
When this happens, you have to go to the hospital within an hour, so you dont get an infection and is in the 
hospital for five days receiving IV antibiotics. The Plan denied your request. The Plan says Medicare criteria 
are not met and there is no indication that an advanced leg pump device is reasonable and necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that you had at least four weeks 
of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and 
supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, 
E0667, E0656).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on January 13, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that you called in January and were told 
these tests would be covered if you submitted a reimbursement form. The Plan denied your request. The Plan 
says these tests were not covered at the time you purchased them. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 tests are an OTC item. The 2022 Evidence of Coverage clearly states that coverage applies to 
eligible at-home COVID-19 tests that are purchased on or after February 1, 2022, and the tests you bought 
were purchased before February 1, 2022. Therefore, we decided that the Plan does not have to pay for the at-
home COVID-19 tests purchased on January 13, 2022.