Persius/hicric huggingface dataset:
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 will require an LTACH level 
of care and is currently stable for discharge. The Plan denied your request. The Plan says the enrollee does not 
meet the guidelines for care in an LTACH. 
 
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 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 would not be clinically 
advantageous and 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 long term acute care hospital (LTACH) services.
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 currently meets LTACH 
admission criteria under CMS guidelines. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 continues on the ventilator. According to the provider notes from 
December 13, 2023, the enrollee has right upper extremity swelling which requires a venous doppler ultrasound 
for evaluation. The enrollee continues to be unresponsive and unable to follow commands. The enrollee's 
continued care needs include evaluation and treatment of right upper extremity swelling, ventilator 
management, gastrostomy tube care, tube feedings, and tracheostomy care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation services 
provided on May 19, 2023. 
 
You asked the Plan to pay for the non-emergent ambulance transportation services. You say that the enrollee 
was bed confined and unable to sit up at the time of transport. The Plan denied your request. The Plan says the 
services could have been provided by another means of transportation. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
 
 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 pay for the non-emergent ambulance transportation 
services. Our reviewer says that the non-emergent ambulance transportation services were not medically 
necessary. Our physician reviewer found the enrollee did not require the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have 
been provided by other means without endangering the enrollees condition. The criterion for coverage is not 
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 non-emergent ambulance transportation services have not been met. 
Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation 
services provided on May 19, 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 the enrollee meets the full criteria for approval of 
services at an IRF. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval of the requested IRF services.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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, and there are no complex nursing or rehabilitation needs. Medically necessary 
services can be provided in 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by codes 
99236 and 99497 billed for date of service October 26, 2022. 
 
You asked the Plan to pay for 99236 and 99497. You say that 99236 and 99497 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says 99236 and 
99497 are denied because they are not supported in 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. 
 
In this case, the CPT Code Manual definition of code 99236 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 85 minutes must be met or exceeded.  The CPT Code Manual definition of code 99497 is advance care planning including the explanation and 
discussion of advance directives such as standard forms (with completion of such forms, when performed), by 
the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family 
member(s), and/or surrogate. 
 
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 pay for 99236 and 99497. Our reviewer says that 
99236 and 99497 are not supported in the documentation. Our reviewer found regarding code 99236, the 
provided document is labeled as an History and Physical Examination (H&P) and does not include any 
reference to a same day discharge. As such, 99236 is not supported. Regarding 99497, the provided document 
does note the enrollees desire to be a full code but does not address a health care proxy (HCP), power of 
attorney (POA), advanced directives, or long-term care goals. As such, 99497 is not supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99236 and 99497 have not been met. Therefore, we decided that the Plan does 
not have to pay for the evaluation and management services described by codes 99236 and 99497 billed for 
date of service October 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric care. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider is out-of-network, and these services were available in-
network. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 pay for the services. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the treating physician did not document, 
in any of the physician notes, on a form, or in an order than the enrollee was not stable for transfer on the dates 
of service. The documentation supports that the enrollee was stable for transfer to an in-network hospital on 
March 5, 2023, at 5:50 pm. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient psychiatric care.
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 cannot walk on their own and needs the 
rehabilitation. The Plan denied your request. The Plan says admission to the IRF is not reasonable and 
necessary.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
requires treatment by multiple therapies, including physical therapy and occupational therapy, but this can be 
provided in a lower level of care. There is documentation that there is 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, but the complexity of their condition doesn't require an IRF stay and services can be 
provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXBladder Detect test provided on April 7, 2023. 
 
You asked the Plan to pay for the CXBladder Detect test. You say that the CXBladder Detect test was 
medically necessary. The Plan denied your request. The Plan says the CXBladder Detect test was 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 pay for the CXBladder Detect test. Our reviewer 
says that the requested CXBladder Detect test is not considered medically reasonable and necessary. Our 
physician reviewer found that the CxBladder is not considered a screening test for urothelial cancer. 
Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the 
results of Cxbladder testing. The current American Urological Association (AUA) guidelines do not 
recommend CxBladder for bladder cancer screening or monitoring. Urinary biomarker tests such as CxBladder 
give significant false-negative results in patients with urothelial cancer and are subject to false-positive results 
in others. The accuracy is poor for low-stage and low-grade tumors.   
 
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 CXBladder Detect test have not been met. Therefore, we decided that the 
Plan does not have to pay for the CXBladder Detect test provided on April 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (P9603) provided on June 14, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 P9603 is "Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled". 
 
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 says that the use of code P9603 is 
not supported by the records provided. Our reviewer found that the medical documentation does not state what medical professional collected the specimen on June 14, 2023, therefore P9603 cannot be validated. 
 
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 services (P9603) provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits, magnetic resonance imaging (MRI) guided 
laser ablation treatment, and associated services provided from July 18, 2023, to July 20, 2023. 
 
You asked the Plan to pay for the outpatient services. You say that you were advised by a Plan representative 
that the services would be covered. You say that you were advised your total out-of-pocket would be $550. 
You say that  The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services performed by a provider that has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. We reviewed the transcript of the call you mentioned and find that you 
did not name the provider you would be seeing. The Plan representative that you spoke with cited general out-
of-network (OON) coverage rules and did not have a specific doctors name to assure coverage with. Since your 
Plan contract has a specific exclusion that indicates certain OON providers who do not accept Medicare 
payment will not be covered, we find that the criteria for Plan directed care are not met in this case. Therefore, 
we decided that the Plan does not have to pay for the office visits, magnetic resonance imaging (MRI) guided 
laser ablation treatment, and associated services provided from July 18, 2023, to July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service July 13, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that 99140 should be paid as billed because it is 
supported in the medical record. The Plan denied your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that this lab testing was medically necessary. 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 June 20, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient physical therapy (PT) services to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON PT services. You say that you need myofascial release physical 
therapy sessions. You say that this therapist is the only one in the area that does a full session of one hour and 
15 minutes. The Plan denied your request. The Plan says the requested services can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve outpatient 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair, portable, captain's 
chair, patient weight capacity up to and including 300 pounds (K0821). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you were told you need to have a heavy-
duty wheelchair because your current wheelchair raises up like it is going to turn over when they try to strap 
you up. The Plan denied your request. The Plan says you do not meet criteria for the requested wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 power wheelchair. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found a group 2 PWC can be covered if the 
medical necessity for a PWC is met and if you also require a drive control interface, power tilt or a power 
recline seating system and if there has been a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a physical or occupational therapist. In this case, you received a group 2 PWC in 
2022 for your mobility needs and there is no current documentation that supports this PWC requires 
replacement. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group 2 standard power wheelchair, portable, captain's chair, patient weight capacity 
up to and including 300 pounds (K0821).