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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on the available information, 
admission to IRF is not reasonable and necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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 
was admitted for surgical management of epidural hematoma and cervical fractures after a fall. 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the sleep study provided on October 13, 
2023, to October 14, 2023. 
 
You asked the Plan to waive the copayment for the sleep study. You say that you were not told that there would 
be a cost share. 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 $275 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $275 copayment for the sleep study. 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 the sleep study provided on October 13, 2023, to October 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an electrocardiogram provided on August 
15, 2023. 
 
You asked the Plan to reduce the copayment for an electrocardiogram. You say that you cannot afford the 
copayment. 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 $175 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $175 copayment for an electrocardiogram. This item/service falls within the in-
network 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. However, since the allowed amount is 
less than the standard copayment, you only owe $61.42. Therefore, we decided that the Plan does not have to 
reduce the copayment for an electrocardiogram provided on August 15, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show that the enrollee needs an intensive care 
team for care. The Plan says services may 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 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 medical 
records support 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. It 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 pay for the interrogation device services (G2066 and 93297) 
provided June 15, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 93297 is interrogation device evaluation(s), (remote) up 
to 30 days; implantable cardiovascular physiologic monitor system, including analysis of 1 or more recorded 
physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s) and 
report(s) by a physician or other qualified health care professional. The definition of code G2066 interrogation 
device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, implantable loop recorder system, or subcutaneous cardiac rhythm monitor system, remote data acquisition(s), 
receipt of transmissions and technician review, technical support and distribution of results. 
 
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 services. Our reviewer found for code 93297, the 
documentation submitted was reviewed and does not meet criteria. The medical record includes a physician 
order and a graph, which does not include sufficient documentation to verify procedure reported. For code 
93297, the provider, a physician or other qualified healthcare professional, evaluates the physiologic data from 
the implantable physiologic cardiovascular monitoring system during a period of up 30 days via telemetric 
communication from both internal and external sensors, to assess whether the device functions normally. 
Report this code for the professional component only. This procedure was not found in medical record. 
 
For code G2066, the documentation submitted was reviewed and does not meet criteria. The medical record 
includes a physician order and a graph, which does not include sufficient documentation to verify procedure 
reported. For Healthcare Common Procedure Coding System (HCPCS) G2066 Interrogation device 
evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, implantable loop 
recorder system, or subcutaneous cardiac rhythm monitor system, remote data acquisition(s), receipt of 
transmissions and technician review, technical support and distribution of results. This procedure was not 
found in medical record. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the interrogation device services (G2066 and 93297) provided June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopic procedure provided on July 
25, 2023. 
 
You asked the Plan to waive the copayment for the endoscopic procedure. You say that you cannot afford the 
copayment. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $350 copayment for the endoscopic procedure. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 endoscopic procedure provided on July 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that that LTACH services are necessary. The 
Plan denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's needs are being met at the current acute care hospital setting. The 
enrollee should continue care until more stable and appropriate for transfer to a lower level of care. There are 
no services at the LTACH that the enrollee requires that are not already available. 
 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 LTACH services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the PrismRA testing (81479) provided on May 18, 2023. 
 
You asked the Plan to pay for the PrismRA testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that this test is not covered in the DEX Diagnostics Exchange Registry. 
 
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. We find that We find that the DEX Diagnostics Exchange Registry shows that 
the PrismRA test is covered. Thus, the Plans denial rationale is not supported. Therefore, we decided that the 
Plan has to pay for the PrismRA testing (81479) provided on May 18, 2023.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric care provided on July 10, 2023. 
 
You asked the Plan to pay for inpatient psychiatric care. You say that you are appealing the denial based on the 
current Medicare rate sheet. The Plan denied your request. The Plan says that their original decision to deny 
payment was correct. 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 inpatient psychiatric care have been 
met. After several attempts to obtain medical records, none have been sent to the Plan. Therefore, we decided 
that the Plan does not have to pay for inpatient psychiatric care provided on July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is necessary due to the failure of 
conservative treatments to address pain and restore function. The Plan denied your request. The Plan says this 
procedure is not supported by research and is not covered. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no imaging showing only modic changes without facet degenerative disc disease or 
stenosis. The cause of pain is not clear and the criteria for coverage have not been met. 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
(K0856) and accessories (E1007, E2377, E2313, E1028, E2620, E0955, E1028, E1012, K0040, E2311, E0960, 
E2607, E0954, and E2363). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with single power option and accessories. You 
say that the requested group 3 power wheelchair with single power option (K0856) and accessories are 
medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested group 3 power wheelchair with single power option (K0856) and accessories.  
 
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 a group 3 power wheelchair with single 
power option and accessories. Our reviewer says that the enrollee does not meet criteria for the requested group 
3 power wheelchair with single power option (K0856) and accessories.  Our physician reviewer found the 
enrollee has obesity and cerebral palsy. She has relied on a power wheelchair chronically and requires a 
replacement. She has intact skin. The enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 power wheelchair with single power option and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
single power option (K0856) and accessories (E1007, E2377, E2313, E1028, E2620, E0955, E1028, E1012, 
K0040, E2311, E0960, E2607, E0954, and E2363).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 34 home health aide visits with 6 skilled nursing visits 
and 4 visits of home physical therapy. 
 
You asked the Plan to pre-approve home health services. You say that the requested home health services are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
clinical documentation dated August 11, 2023, indicated that the enrollee was evaluated for an annual well 
visit. The enrollee was noted to have had a fall and was to start physical therapy. The enrollee was noted to 
have been experiencing repeated falls. The enrollee is noted to have normal muscle tone and coordination and 
was walking slowly. Home therapy was ordered for difficulty walking and frequent falls. A home health care 
plan dated September 8, 2023, indicated that the enrollee requires assistance with daily activities, including 
dressing, feeding, and errands. 
 
The enrollee is noted to have gait instability and be a risk for falling. The enrollee would benefit from home 
health physical therapy and has been approved for 6 visits. This should allow for an evaluation of their level of 
function and mobility and if further therapy sessions are required. The enrollee does not have skilled nursing 
care needs, including wound care, management of a feeding tube, or administration of IV medications. The 
enrollee has not required recent hospitalization. The enrollee is noted to require assistance with daily activities, 
but there is insufficient documentation indicating their level of function with these daily activities and why the 
enrollee requires the intensity of home health aide assistance being requested. 
 
Therefore, the additional home health skilled nursing care, physical therapy and personal care assistance 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 34 home health aide visits with 6 skilled nursing visits and 4 visits of home 
physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapies provided on August 3, 2023, to August 10, 
2023.  
You asked the Plan to pay for psychotherapies. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says you must attempt to consult the attending or primary care 
physician about the services furnished and document the consent or declination date to consultation, and the 
date of consultation in the enrollee's medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that a clinical social worker must agree to meet the 
requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapies have not been met. Therefore, we decided that the Plan does not have to pay for 
psychotherapies provided on August 3, 2023, to August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 03, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on April 03, 2023.