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 is stable and suitable for transfer to an 
IRF. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 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 complexity of the enrollees 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 sepsis, urinary tract infection and acute respiratory failure. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist office visit provided on July 13, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for specialist 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 specialist office visit provided on July 13, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional evaluation of fine needle aspirate (88177) billed 
for date of service March 30, 2022. 
 
You asked the Plan to pay for additional evaluation of fine needle aspirate. You say that the services at issue 
have been billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 additional evaluation of fine needle aspirate is an add-on code and has not been billed with an appropriate 
primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for additional evaluation of fine needle aspirate (88177) billed 
for date of service March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87631, 87634) provided on October 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that panel testing for more than 5 respiratory 
pathogens performed in the Part B outpatient setting are non-covered. 
 
We looked at the file and Medicare rules. The panel tested for more than 5 pathogens. 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 (87631, 87634) provided on October 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service June 17, 
2022. 
 
You asked the Plan to pay for procedure code 76770. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76770 is bundled into payment for code 93975. 
 
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 76770 
is a column II code to column I code 93975. 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 76770 billed for date of service June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99214) billed for date of 
service May 17, 2022. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 
We find that CPT code 99214 is not supported in the case record. Specifically, no medical records have been 
provided in support of the services at issue. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Based on this information, we decided that Medicare rules for coverage of an office or other outpatient visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an office or other outpatient visit (99214) billed for date of service May 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services rendered on June 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with mismatched 
diagnosis codes. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services 
rendered on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 18, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 is considered bundled and 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 procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bathroom safety equipment provided on August 4, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment (DME) supplies. You say that you know the purchase 
of the equipment is covered and you want to be reimbursed. The Plan denied your request. The Plan says the 
bathroom safety equipment was purchased from an out-of-network supplier. Additionally, prescription was not 
received from your provider. 
 
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 bathroom safety equipment provided on August 4, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy and 
services provided on June 24, 2022. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy and services. You say that 
you do not believe you owe this copayment of $200. You also say you think this procedure is something you 
needed in order to swallow your food and not have it come back up. 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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $200 copayment for an esophagogastroduodenoscopy and services. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 
esophagogastroduodenoscopy and services provided on June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service February 10, 
2022. 
 
You asked the Plan to pay for procedure code 88321. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 2, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 is considered bundled and 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 procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service April 2, 2022.
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 is stable to transfer to an 
LTACH for continuation of care. The Plan denied your request. The Plan says based on Medicare guidelines, 
the requested LTACH services do not meet the requirements for approval. 
 
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 has undergone multiple surgeries and procedures, and only recently 
received a tracheotomy.  The enrollee remains on a ventilator but appears unstable for attempted weaning until 
recently.  There is no evidence that the enrollee has failed formal weaning trials or that the enrollee requires 
services that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same 
level of care, there is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the 
current acute care hospital until such time no acute services are required.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261) purchased on February 1, 2022, 
from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid. You say that since you were advised you could file a claim to be 
reimbursed, combined with the lack of transparency as to who the approved hearing aid providers are, warrants 
payments of the allowance. The Plan denied your request. The Plan says you received this hearing aid from an 
OON provider, you did not set up a hearing profile, and there was no provider assigned prior to this date of 
service. The Plan also says that there is no record of any calls from you or your wife to the Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aid (V5261) purchased on February 1, 2022, from an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have trouble walking and are very weak, you 
need rehab to regain strength. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that daily 
skilled services are required. There is no documentation that you require the services on an inpatient basis, only 
in a skilled nursing facility setting. Records do not support that services in the home with home health care or 
in a long-term care facility on a part time basis are not appropriate in this case. 
 
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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 procedure code 70450 billed for date of service July 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echo exam provided on July 27, 2022. 
 
You asked the Plan to waive the copayment for echo exam. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $100 copayment for echo exam. 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 echo exam provided on July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional days of an inpatient psychiatric admission. 
 
You asked the Plan to pre-approve additional days of an inpatient psychiatric admission. You say that the 
requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 additional days of an inpatient psychiatric admission. Our reviewer says that the requested additional services are not medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee is not showing any danger to self or 
others, auditory or visual hallucinations and is without aggressive behaviors while not showing any acute 
threats of safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional days of an inpatient psychiatric admission have not been met. 
Therefore, we decided that the Plan does not have to pre-approve additional days of an inpatient psychiatric 
admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, hereditary diabetes/obesity genetic analysis, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on June 1, 2022.