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 services are medically necessary for the enrollee 
to regain their strength back. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for admission to an IRF.  
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says these services needed can be provided safely in other 
settings.  
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee's 
medical problems are stable. The enrollee does not require treatment by multiple therapies. 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the urine polymerase chain reaction (PCR) panel 
provided on April 11, 2023. 
 
You asked the Plan to pre-approve the urine PCR panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the urine PCR panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the standard of care for the evaluation of urinary incontinence/infection is 
urinalysis with urine culture and sensitivity. The PCR testing is not medically 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 the urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the urine polymerase chain reaction (PCR) panel provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits provided on 
February 2, 2023, and March 3, 2023.  
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you disagree with the 
copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for Medicare-covered in-network specialist services.  
 
You have been asked to pay a $30 copayment for each specialist office visit provided on February 2, 2023, and 
March 3, 2023. These services falls within the physician/practitioner services, including doctor's office visits 
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 the specialist office visits 
provided on February 2, 2023, and March 3, 2023.
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 have been for outpatient therapy and are 
recommended for the IRF. The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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. While you may need 
physical and/or occupational therapy, there is no documented need for 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the shoulder x-ray provided on May 11, 
2023. 
 
You asked the Plan to waive the copayment for the shoulder x-ray. You say that you already paid a copayment 
for the office visit. 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 $40 
copayment for in-network outpatient diagnostic tests, including x-rays. 
 
You have been asked to pay a $40 copayment for the shoulder x-ray. This item/service falls within the in-
network outpatient diagnostic tests, including x-rays 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 the shoulder x-ray provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on March 9, 2023. 
 
You asked the Plan to pay for an office visit. You say that you disagree with the denial and have submitted all 
records for the date of visit. The Plan denied your request. The Plan says two of the billed diagnosis codes 
cannot be reported together. 
 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that D18.01 has an Excludes1 note in relation to D22.5. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for an office visit have not been met. Therefore, we decided that the Plan does not have to pay for 
an office visit (99213) provided on March 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C. 
 You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Gamunex-C is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the drug. Our reviewer says that 
Gamunex-C is not medically necessary. Our physician reviewer found that the requested use of Gamunex-C is 
FDA- approved. However, Gamunex-C is not supported by one of the major drug compendia or by clinical 
research. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gamunex-C.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 20, 2023, billed with 
codes 96365-59, 96366-59, and 96521. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT 
regimen.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. The services provided are not payable as this 
is a non-covered service. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on April 20, 2023, billed with codes 96365-59, 96366-59, and 96521.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 1, 2022, billed 
with codes 93312-26-59 and 93503. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 93312 is a column II code to column I code 00567; however, 93312 
was billed with a modifier.  
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found an interpretation and report of the 
transesophageal echocardiography (TEE) was not included in the documentation, and therefore procedure code 
93312 cannot be confirmed as a distinct procedural service from anesthesia performed. Also, procedure report 
does not include documentation of a right heart catheterization, and therefore procedure code 93503 cannot be 
verified. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on November 1, 2022, billed with codes 93312-
26-59 and 93503.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation provided on March 24, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the evaluation. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for the evaluation provided on March 24, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 1, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this claim was denied inappropriately due to 
a provider registry issue. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 87634 billed for date of service March 3, 
2023. 
 
You asked the Plan to pay for procedure code 87634. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87634 is bundled into payment for code 87798. 
 
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 87634 
is a column II code to column I code 87798. 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 87634 billed for date of service March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter. 
 
You asked the Plan to pre-approve the Dexcom G6 transmitter. You say that the transmitter is a medical 
necessity. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands of 
products and this plan only covers Freestyle Libre CGMs.  
 
 We looked at the file and Medicare rules. Medicare rules say that Plans may limit coverage to certain brands 
of products and this plan only covers Freestyle Libre CGMs. 
 
We looked at the file and Medicare rules. Medicare rules say that plans may limit coverage to certain brands of 
products and that the plan only covers FreeStyle Libre CGMs. Based on this information, we decided that 
Medicare rules for coverage of the Dexcom G6 transmitter  have not been met Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 transmitter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the synthetic sheepskin pad billed with code E0188 for date 
of service April 6, 2023. 
 
You asked the Plan to pay for code E0188. You say that you have provided documentation to support payment. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for this specific item.  Specifically, the proof of delivery 
that you supplied addresses only the continuous passive motion machine (code E0935) itself.  There is no 
mention of the pad or code E0188 at all. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
synthetic sheepskin pad billed with code E0188 for date of service April 6, 2023.
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 require physical and occupational services to 
regain your mobility. The Plan denied your request. The Plan says you do not meet the criteria for admission to 
an IRF.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 the services are medically necessary for you to 
receive your therapy services. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to an IRF.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 codes 81301 and 81194 billed for date of service 
January 23, 2023. 
 
You asked the Plan to pay for procedure codes 81301 and 81194. You say that medical records were submitted. 
The Plan denied your request. The Plan says payment for codes 81301 and 81194 is bundled into payment for 
code 81455. 
 
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 file shows that a somatic molecular panel test was provided. In this case, we have confirmed that codes 
81301 and 81194 are column II codes to column I code 81455. The records do not show that the codes at issue 
were unusual non-overlapping services. Furthermore, panel testing is billed with a single code and one unit of 
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 codes 81301 and 81194 billed for date of service January 23, 2023.