Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted laparoscopy procedure (49329) provided on 
December 3, 2022. 
 
You asked the Plan to pay for the unlisted laparoscopy procedure (49329). You say that the medical records 
should be reviewed. The Plan denied your request. The Plan says procedure code 49329 is not supported by the 
medical records submitted. 
 
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 49329 is unlisted laparoscopy procedure, abdomen, 
peritoneum and omentum. 
 
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 unlisted laparoscopy procedure (49329). Our reviewer 
says that procedure code 49329 is not supported. Our reviewer found that the operative report does not include 
documentation to support the unlisted procedure code. 
 
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 unlisted laparoscopy procedure (49329) have not been met. Therefore, we 
decided that the Plan does not have to pay for the unlisted laparoscopy procedure (49329) provided on 
December 3, 2022.
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 LTACH level of care is the only options 
for a safe discharge due to the need for frequent nursing care, daily physician management, daily labs, frequent 
vital signs, and physical and occupational therapy. The Plan denied your request. The Plan says an LTACH 
admission 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 that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the UTI Gx panel (87481, 87500, 87640, 87641, 87651, 
87653, 87798) provided on January 12, 2023.  
 
You asked the Plan to pay for the UTI Gx panel. You say that this testing was medically necessary.  The Plan 
denied your request. The Plan says the requested testing exceeded the enrollee's needs.  
 
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 UTI Gx panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the review indicates that the enrollee was evaluated on January 12, 2023, for complaints of 
increased urinary frequency. No provider medical records were provided other than the lab report and this 
diagnosis from billing. This test was ordered by a physician assistant who is not a participating provider with 
the enrollees plan. There was no submitted documentation indicating that this enrollee was at risk for urinary 
tract infection (UTI) complications nor that the enrollee was seen by a urology specialist. There was no clinical 
rationale for the obtained laboratory studies. The review has determined that the items/services at issue in this 
case were not medically 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 UTI Gx panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the UTI Gx panel (87481, 87500, 87640, 87641, 87651, 87653, 87798) provided on January 
12, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the opioid dependence services provided on February 20, 
2023. 
 
You asked the Plan to pay for the opioid dependence services. You say that the Plan must coordinate benefits 
and timely payment. 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 opioid dependence 
services provided on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator 
provided on February 01, 2023, to March 01, 2023. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you were not 
advised that this would be partially paid for. 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 20% 
coinsurance for Medicare-covered durable medical equipment (DME) items. 
 
You have been asked to pay 20% coinsurance for an automatic external defibrillator. This item/service falls 
within the Medicare-covered durable medical equipment (DME) items 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. The total you owe is $1232.38 
($6161.90 allowed amount x 20% = $1232.38). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an automatic external defibrillator provided on February 01, 2023, to March 01, 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  The Plan denied your request. The Plan 
says an LTACH admission is not medically necessary, and the enrollee's needs can be met in the current 
hospital setting.  
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation IRF admission and 
services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are necessary for the 
enrollee to regain maximum function. The Plan denied your request. The Plan says the IRF services requested 
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 that the clinical documentation does not specify any active medical comorbidities. 
Thus, the complexity of the enrollees documented nursing, medical, and rehabilitation needs would not be 
expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
Clinical documentation shows that while the enrollee may have a need for physical therapy and/or occupational 
therapy, the documentation does not show that the enrollee requires an intensive rehabilitation regimen. IRF 
criteria 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an acute inpatient rehabilitation IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography (75710) provided on November 14, 2022. 
 
You asked the Plan to pay for 75710. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the records do not support this code. 
 
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 75710 is angiography, extremity, unilateral, radiological 
supervision and interpretation. 
 
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 75710. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the procedure report describes an intervention performed in extremity 
which includes radiological interpretation and report. The procedure report does not include documentation to support 75710. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 75710 have not been met. Therefore, we decided that the Plan does not have to 
pay for angiography (75710) provided on November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Inpatient hospital care provided on November 12, 2022, to 
November 13, 2022, billed with evaluation and management (EM) code 99223. 
 
You asked the Plan to pay for the Inpatient hospital care provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the Plan says 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 Inpatient hospital care provided. Our reviewer found 
that the medical decision making was not of high complexity. As such, the billing of CPT 99223 is not 
supported. 
 
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 Inpatient hospital care provided have not been met. Therefore, we decided 
that the Plan does not have to pay for Inpatient hospital care provided on November 12, 2022, to November 13, 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of acute rehabilitation services for the enrollee. The Plan denied your request. The Plan says the enrollee does 
not meet the guidelines for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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. 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthroscopy (29871) provided on April 13, 2022. 
 
You asked the Plan to pay for the knee arthroscopy (29871). You say that modifier 59 should suppress the CCI 
conflict. You say that the medical records support that separate payment is necessary, and the claim should be 
processed for payment. The Plan denied your request. The Plan says procedure code 29871 is considered 
inclusive to procedure code 29881. 
 
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 29871 is a column II code to column I code 29881; however, 29871 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the knee arthroscopy (29871). Our reviewer says that 
modifier -59 is not supported. Our reviewer found the operative report describes irrigation and minimal 
debridement in the same anatomical location as the more comprehensive procedure. 
 
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 knee arthroscopy (29871) have not been met. Therefore, we decided that the 
Plan does not have to pay for the knee arthroscopy (29871) provided on April 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. 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 per Medicare 
rules, home health services in addition to hospice services is a duplication of services. 
 
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 home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous moderate sedation for the first 15 minutes 
(D9239) and intravenous moderate sedation for each additional 15 minutes (D9243). 
 
You asked the Plan to pre-approve the intravenous moderate sedation for the first 15 minutes (D9239) and 
intravenous moderate sedation for each additional 15 minutes (D9243). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this service is not covered in your dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
intravenous moderate sedation for the first 15 minutes (D9239) and intravenous moderate sedation for each 
additional 15 minutes (D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant placement (D6010). 
 
You asked the Plan to pre-approve an implant placement. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant placement (D6010).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF services will give you more time to receive the 
care you need. The Plan denied your request. The Plan says admission to a SNF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided on March 20, 2023, through March 30, 2023. 
 You asked the Plan to pay for IRF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the enrollee did not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not require treatment by multiple therapies. While the medical record 
supported a need for physical or occupational therapy, there was no documented need for intensive 
rehabilitation services. Medically necessary care could have been provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for acute inpatient rehabilitation facility (IRF) admission and services provided on March 20, 2023, 
through March 30, 2023.