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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF level of care is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies as an 
outpatient or at a skilled nursing facility (SNF) may be approved upon request.  
 
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. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray interpretation provided on April 19, 2023, billed with 
modifier -76. 
 
You asked the Plan to pay for the interpretation as billed. You say that this was correctly billed for the second 
interpretation by this provider. The Plan denied your request. The Plan says that because no claim was paid for 
an initial x-ray interpretation from this physician, the use of modifier -76 is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the evidence in the file does not support the Plan's denial rationale 
in this case. Payment was denied for this claim due to the use of modifier -76, stating that because a prior x-ray 
was performed by another physician, modifier -77 should be used. There is some mention of a claim without a 
modifier -76 being denied for untimely filing since it was submitted past 120 days. Though not the subject of 
this review, denial for untimely filing would only be appropriate under Medicare for claims submitted one year 
after the date of service.  
 
Moreover, the records submitted do clearly show that the rendering provider for this claim did perform two 
distinct interpretations of two x-rays, supporting the use of modifier -76 on this claim, regardless of whether the 
claim for the first x-ray interpretation was paid or denied. Based on this information, we find that the denial of 
payment based on the non-supported modifier is not substantiated. Therefore, we decided that the Plan has to 
pay for the x-ray interpretation provided on April 19, 2023, billed with modifier -76.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 8, 2023, 
to February 11, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the requested services are not required due to the 
enrollee's medical history. 
 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission it was reasonable for the admitting physician to expect that the enrollees necessary hospital care 
(including earlier emergency department and/or observation care) would span two midnights with supporting 
documentation of the enrollees history and comorbidities, signs and symptoms, current medical needs, and risk 
of an adverse event. 
 
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 pay for the acute inpatient hospital care provided February 8, 2023, to February 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 rendered on January 23, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim does not meet coding standards. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that P9603 is not supported. The record does not support that travel to collect a laboratory specimen from home bound or nursing home bound 
patient was performed. 
 
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 procedure code P9603 rendered on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the standard wheelchair (K0001) purchased 
August 14, 2023. 
 
You asked the Plan to reimburse you for the wheelchair. You say that the provider you were referred to did not 
have the correct sized wheelchair and would not refer you to another vendor. The wheelchair should be 
covered, and you are requesting reimbursement. The Plan denied your request. The Plan says the item was 
purchased from a supplier who does not participate with Medicare. 
 
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 the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the standard wheelchair 
(K0001) purchased August 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90715, 90471, 72125, 73080, 73030, and 
72170 for date of service September 6, 2023. 
 
You asked the Plan to pay for procedure codes 90715, 90471, 72125, 73080, 73030, and 72170. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are 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 codes 90715, 90471, 72125, 73080, 73030, and 72170 are not payable as billed. Specifically, 
codes 90471, 73080, 73030, and 72170 are assigned a Q1 indicator (Packaged APC payment if billed on the 
same claim as a HCPCS code assigned status indicator S, T, or V"). CPT code 90715 is assigned a N 
indicator (Paid under OPPS; payment is packaged into payment for other services. Therefore, there is no 
separate APC payment.) CPT code 72125 is assigned a Q3 indicator (Composite APC payment based on 
OPPS composite-specific payment criteria. Payment is packaged into a single payment for specific 
combinations of services.) CPT code 99284 25 that was paid was assigned final status indicator V since the 
APC assigned was 5024. CPT code 70450 that was paid was assigned final status indicator S since the 
Composite APC assigned was 8005. These services would not be separately payable. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 90715, 90471, 72125, 73080, 
73030, and 72170 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 90715, 90471, 72125, 73080, 73030, and 72170 for date of service September 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
August 11, 2023, to August 15, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you dont agree with 
the copayment assessed. 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 $250 
copayment for inpatient hospital care. 
 
You have been asked to pay a $250 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital care 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 
$500. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay 
provided on August 11, 2023, to August 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-ray, nerve conduction study and an 
office visit on August 17, 2023. 
 You asked the Plan to waive the copayments for the x-ray, nerve conduction study and an office visit. You say 
that you want to appeal the amount being charged. 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 $15 
copayment for each Medicare-covered standard x-ray service. You must pay a $25 copayment for Medicare-
covered non-radiological diagnostic services. You must pay a $30 copayment for services from a specialist or 
under certain circumstances, treatment by a nurse practitioner, physicians assistant or other non-physician 
health care professional in a specialists office (as allowed under Medicare). For all services it's $15 + $25 + 
$30 = $70. Therefore, results in the total cost sharing amount of $70. 
 
You have been asked to pay a $15 copayment for the x-ray, a $25 copayment for nerve conduction study and a 
$30 copayment for an office visit. This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies and physician/practitioner services, including doctors office visits benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the x-ray, nerve conduction study and an office visit on 
August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
06, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be 
responsible for this service. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on June 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 26440 and 26460 rendered on September 27, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 the 
provided records do not support that procedure code 26440 and 26460 were separate and distinct procedures 
from CPT 26525. The records document one surgical reconstruction through one incision on one finger on 09/07/2023, a left middle finger PIP (proximal interphalangeal) joint contracture release and boutonniere 
reconstruction. 
 
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 procedure code 26440 and 26460 rendered on September 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the steroid injection provided on August 
17, 2023. 
 
You asked the Plan to waive the copayment for the injection. You say that you have never paid this high of a 
copayment for a steroid injection and would like the fee waived. 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 $280 
copayment for outpatient hospital services. 
 
You have been asked to pay a $280 copayment for the steroid injection. 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. Therefore, we decided that the Plan does not have to waive the copayment for the steroid 
injection provided on August 17, 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 just had hip surgery, is 93 years old, and 
needs the help. You also say that the enrollee still drives, takes care of herself and needs to go into 
rehabilitation to start getting back around. The Plan denied your request. The Plan says based on the available 
information, admission to IRF is not reasonable and necessary, as the enrollee's condition does not meet the 
Medicare rules.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation 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 the enrollee 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 pre-approve cardiology services. 
 
You asked the Plan to pre-approve cardiology services. 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. 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 cardiology services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you had a recent low-risk radionuclide stress test, as well as an echocardiogram 
showing normal ejection fraction with no wall motion abnormalities. Guidelines do not support a need for 
invasive cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be 
considered medically appropriate and necessary in your clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiology services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cardiology services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B drugs and outpatient surgery on 
September 5, 2023. 
 
You asked the Plan to waive the cost share for the Part B drugs and outpatient surgery. You say that you were 
not aware of the cost. 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, infusion drugs, and all other drugs covered under Medicare Part B. You 
must pay a $200 copay for each Medicare-covered visit to an outpatient hospital facility. The provier billed in 
the amount of $1,764 and the allowed amount is $294.73. For the service it's $294.73 x 20% = $58.95. For both 
services it's $58.95 + $200 = $258.95. 
  
You have been asked to pay a $258.95 cost share for the Part B drugs and outpatient surgery. This item/service 
falls within the Medicare Part B prescription drugs and outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost share for the Part B drugs and outpatient surgery on September 5, 2023.