Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and pathology test (83036). 
 
You asked the Plan to pay for the office visit and pathology test. You say that the cost share is wrong. 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 $300 deductible which applies to the office visit and pathology test.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which 
applies to the office visit and pathology test. This cost sharing is a contractual obligation that had not been met 
at the time the office visit and pathology test was received on August 30, 2023. Therefore, we decided that the 
Plan does not have to pay for the office visit (99214) and pathology test (83036).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 billed for date of service August 30, 
2023. 
 You asked the Plan to pay for procedure code 99308. The Plan denied your request. The Plan says payment for 
code 99308 is bundled into payment for code 11042. 
 
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 99308 
is a column II code to column I code 11042. 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 99308 billed for date of service August 30, 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 are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval.  
 
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 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. 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 patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient clinic services provided on September 22, 2023 to 
September 27, 2023. 
 
You asked the Plan to pay for the outpatient clinic services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is 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 CPT code. 
 
We find that the outpatient services are not supported in the medical record. Specifically, the services were 
provided at an outpatient clinical affiliated with a hospital where the enrollee was an inpatient in the 72 hours 
prior to the outpatient services. The outpatient services are not seperately payable. Based on this information, 
we decided that Medicare rules for coverage of the outpatient clinic services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient clinic services provided on September 22, 2023 to 
September 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve the panniculectomy. You say that due to your weight loss you have to wear 
corsets to prevent pain and irritation. These corsets also have caused infections. The Plan denied your request. 
The Plan says the criteria for coverage have not been met. 
 
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 panniculectomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that you have significant weight loss and a grade one 
pannus. The record provided does not document the presence of chronic intertrigo for three months or that the 
weight has been stable for six months. The elements of the coverage criteria are not satisfied. 
 
 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 panniculectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a panniculectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator (E1390). 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the provider 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. Therefore, we decided that the Plan does not have to pay for the 
portable oxygen concentrator (E1390).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on February 16, 
2022, to March 29, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the claim was accurately billed with the 
appropriate DRG. The Plan denied your request. The Plan says in order to determine whether Medicare claims 
were billed in compliance with coverage, coding, payment, and billing policies, medical records would need to 
be provided for review. If no response is received within the expected timeframes, the reviewer shall deny the 
claim, in full or in part, as not reasonable and necessary. 
 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 the inpatient care have been met. 
Medical records were not received from the provider in the timeframe allowed. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital services provided on February 16, 2022, to March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on August 28, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that this 
copayment is too high, and no one advised you. If you had known the copay was that high you would have 
canceled the test. 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 $180 
copayment for outpatient hospital services. 
 
You have been asked to pay a $180 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient hospital services 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 $106.66. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on August 28, 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 are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says you do not meet the requirements for approval.  
 
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 your medical complexity does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. You do not require an intensive rehabilitation therapy, and it is 
unclear if you would tolerate. There is not a reasonable expectation that you will be able to benefit from the 
intensive rehabilitation program provided in an inpatient rehabilitation facility.  
 
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 Chemical Cauterization of granulation tissue (17250) 
provided on July 03, 2023, to July 31, 2023. 
 
You asked the Plan to pay for Chemical Cauterization of granulation tissue (17250). You say that the 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 Chemical Cauterization 
of granulation tissue (17250) provided on July 03, 2023, to July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nails and trimming of dystrophic nails 
provided on September 21, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for debridement of nails and trimming of dystrophic nails. You say that the services 
should be covered. The Plan denied your request. The Plan says this 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 debridement of nails and trimming of dystrophic 
nails provided on September 21, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower extremity study (93925), radiological exam 
equipement transport (R0070), and set up (Q0092) provided on August 18, 2023. 
 
You asked the Plan to pay for the lower extremity study (93925), radiological exam equipement transport 
(R0070), and set up (Q0092). You say that the services were 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 lower extremity 
study (93925), radiological exam equipement transport (R0070), and set up (Q0092) provided on August 18, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic visits provided on April 19, 2023. 
 
You asked the Plan to pay for chiropractic visits. You say that you were not told this provider was out-of-
network. 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 chiropractic visits 
provided on April 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services rendered from August 1, 2022, to 
August 30, 2022. 
 
You asked the Plan to pay for the services. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the physician's plan of care for home health services was invalid. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services must be submitted with an 
order. 
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that in 
this case, the documentation available for review does not include a physicians order to support the services 
billed. 
 
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 home health services rendered from August 1, 2022, to August 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with altered mental status in the setting of sepsis secondary 
to pneumonia. The record indicates that the enrollee has ongoing acute medical issues and still requires acute 
care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving 
but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
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 pay for the inpatient hospital services provided on September 6, 
2023, to September 12, 2023. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says the outpatient clinic services were provided within the 72-
hours prior to the 09/6/2023 admission date indicated on the claim. Therefore, services provided are included in 
the inpatient payment. 
 The Plan must follow Medicare rules. Medicare rules say that within 3 days prior to and including the date of 
the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment.  
 
We looked at the file and Medicare rules. While the outpatient services were correctly reported on the inpatient 
claim, the date of service on which they were rendered was not included in the date of service range of the 
claim. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital care 
have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services 
provided on September 6, 2023, to September 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve blocks. 
 
You asked the Plan to pre-approve peripheral nerve blocks. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that when the enrollees pain appears to be due to a 
classic mononeuritis but the neuro-diagnostic studies have failed to provide a structural explanation, selective 
peripheral nerve blockade can usually clarify the situation but this is only for diagnostic purposes and not long 
term treatment. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve peripheral nerve blocks. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found peripheral nerve blocks are only 
covered for use for diagnostic purposes. The records which were provided for review suggest that the therapy 
was to be provided for therapeutic use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripheral nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve peripheral nerve blocks.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuropsychological testing (codes 96132 and 96138) 
provided on August 30, 2023. 
 
You asked the Plan to pay for the neuropsychological testing. You say that procedure code 96132 needs to be 
reconsidered for payment because it is part of the neuropsychological evaluation which helps with planning the 
next steps in the patient's care. The Plan denied your request. The Plan says the requested services are not 
reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that these diagnostic tests are used when mental illness is 
suspected, and clarification is essential for the diagnosis and the treatment plan. 
 
 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 neuropsychological testing. Our reviewer 
says that based on the medical records provided there is no documentation that the items/services at issue in 
this case meet Medicare criteria for medically reasonable and necessary. Our physician reviewer found the 
provided records in this case do not document that a mental illness is suspected, and clarification is essential for 
the diagnosis and the treatment plan. 
 
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 pay for the neuropsychological testing (codes 96132 and 96138) provided on August 
30, 2023.