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

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you will need inpatient admission 
after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation you will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found there is no documentation of the need for at least a 2 midnight stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76492, 64447, and 64450 billed for date of 
service October 26, 2022. 
 
You asked the Plan to pay for procedure codes 76492, 64447, and 64450. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for code 64447 is bundled into payment for 
code 01402. The Plan says that code 76942 is not supported. The Plan also says that code 99100 is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT code 76492 is not supported 
in the medical record. Specifically, the documentation submitted did not include documentation of permanently 
recorded images; therefore, the billed service cannot be verified. In this case, we have confirmed that codes 
64447 and 64450 are column II codes to column I code 01402. 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 codes 76492, 64447, and 64450 
billed for date of service October 26, 2022.
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 needs to continue doing physical 
therapy. The Plan denied your request. The Plan says an IRF admission is not medically 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 that the complexity of the enrollee's nursing, medical and rehabilitation can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional 100 units of Xeomin. 
 
You asked the Plan to pre-approve the additional 100 units. The Plan denied your request. The Plan says the 
additional 100 units 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 additional 100 units of Xeomin. Our 
reviewer says that the additional 100 units is not medically necessary. Our physician reviewer found that there 
is no support that 200 units of Xeomin for treatment of sialorrhea meets the Medicare criteria for safe, 
effective, reasonable, or 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 additional 100 units have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the additional 100 units of Xeomin
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 LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee is not stable enough for an 
LTACH admission. 
 
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 is receiving appropriate care in the current acute care setting as provided 
by Health Plan. The documentation does not support that LTACH services are medically appropriate at this 
time.  
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vasectomy (55250) provided on May 2, 2023. 
 
You asked the Plan to pay for the surgical service. You say that this was necessary to prevent potential future 
pregnancy and birth complications. You say that your primary doctor recommended this as the safest form of 
birth control. You also say that you were surprised to see this was not covered. The Plan denied your request. 
The Plan says vasectomies for the purpose of sterilization is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment would be made for sterilization 
procedures if it is a preventive measure. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical service have not been met. Therefore, we decided that the Plan does not have to pay 
for the vasectomy (55250) provided on May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 21, 2022, billed 
with evaluation and management (EM) code 99223. 
 
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 that the level of care 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We asked our physician 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 
that documentation does not support the billed code Our reviewer found that the review has determined that 
CPT 99223 was not supported in the medical records. Specifically, there was no comprehensive history 
documented on the day of service in question. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on November 21, 2022, billed with evaluation 
and management (EM) code 99223.
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to 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's condition is best and most safely treated in the acute care hospital 
setting. There are no services at an LTACH that the enrollee is not able to get in their current setting. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis provided on April 24, 2023. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that you would like your insurance to pay you 
for the foot orthosis you received from a provider no enrolled in Medicare. The Plan denied your request. The 
Plan says the provider is not Medicare certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that you received the foot orthosis from a provider that is not 
enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the ankle foot 
orthosis provided on April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on May 20, 
2023. 
 
You asked the Plan to waive the deductible for the laboratory services. You say that laboratory services should 
not be put towards the deductible. 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. Your 
contract with the Plan says that there is a $625 deductible which applies to in-network outpatient diagnostic 
tests and therapeutic services. Your contract with the Plan also says that you must pay a $0 copayment after 
meeting the deductible for in-network laboratory services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $625 deductible which applies to in-network outpatient diagnostic tests and therapeutic 
services. This cost sharing is a contractual obligation that had not been met at the time the laboratory services 
was received on May 20, 2023. Therefore, we decided that the Plan does not have to waive the deductible for 
the laboratory services provided on May 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an office visit. 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 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 an office visit provided on May 17, 2023, by an 
OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have waive the cost share for the Ziextenzo injection (Q5120) provided on 
August 13, 2021. 
 
You asked the Plan waive the cost share for Ziextenzo. You say that you had a chemotherapy injection on 
August 12 that was paid for.  You say that this claim is for the injection that you received the next day. You 
also say that you do not understand why you have to pay a 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 20% 
coinsurance for Chemotherapy Drugs.  
 
You have been asked to pay a 20% coinsurance for Ziextenzo. This item/service falls within the Chemotherapy Drugs 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 waive the cost share for the Ziextenzo injection (Q5120) 
provided on August 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed for date of service April 21, 
2023.  
 
You asked the Plan to pay for procedure code 69990. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 69990 is bundled into 
payment for code 36224. 
 
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 69990 is a column II code to column I code 36224 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 69990 billed for date of service April 21, 2023.
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 August 23, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim is billed correctly and should be 
paid. 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 August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says your 
benefit plan does not cover more than 40 one-way trips per plan year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 40 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 10 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve 10 additional routine transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lightweight wheelchair provided from September 26, 2022, 
to October 25, 2022. 
 
You asked the Plan to pay for lightweight wheelchair. You say that you are appealing with supporting records. 
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 item. 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 a lightweight wheelchair provided from September 26, 2022, to October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 Sensor. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. 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 specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a Dexcom G6 Sensor. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
Sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A6209 for date of service April 14, 2023. 
 
You asked the Plan to pay for code A6209. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines for code A6209 billed without 
modifier A1-A9 will be denied. 
 
We looked at the file and Medicare rules. Review of the file shows that code A6209 was not billed with a 
required modifier. Based on this information, we decided that Medicare rules for coverage of code A6209 have 
not been met. Therefore, we decided that the Plan does not have to pay for code A6209 for date of service April 
14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Neuropsychological Testing (96132; 96133; 96136; 
96137). 
 
You asked the Plan to pre-approve the Neuropsychological Testing. You say that the service is medically 
necessary. The Plan denied your request. The Plan says The records indicate that the member is being 
treated for memory loss, depression and anxiety, and is responding well to his medications. It is not clear why 
neuropsychological testing has been requested. The records do not indicate if a neurobehavioral status 
examination had been completed and was unclear as to how neuropsychological testing would inform 
treatment. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is considered medically 
necessary when the criteria listed in the Medicare Rules section is met. 
 
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 Neuropsychological Testing. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there does not appear 
to be a specific need for the testing which is asked for. Neuropsychological testing is not considered reasonable 
or medically necessary for the treatment of this patients condition utilizing the information provided. 
 
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 Neuropsychological Testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Neuropsychological Testing (96132; 96133; 96136; 96137).