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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition has stabilized, 
and they are ready for discharge from the acute care hospital. The Plan denied your request. The Plan says 
based on the medical records provided, admission to the LTACH is not medically necessary at this time. 
 
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 the 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that the enrollee needs this treatment because the previous 
treatment had no improvements. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that Eylea is 
not medically necessary. Our physician reviewer found that the enrollee has exudative age-related macular 
degeneration with neovascularization. Although the medication is a new start there is no indication that the 
enrollee has tried and failed the Plans preferred step one alternatives. Also, there is no indication that the 
enrollee has a contraindication to or would have an adverse effect from the Plans preferred step one 
alternatives. Therefore, the elements of the coverage criteria are not satisfied, and the requested service cannot 
be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 27810-54-LT billed for date of service February 28, 
2023. 
 
You asked the Plan to pay for code 27810-54-LT. You say that this claim should be reprocessed. The Plan 
denied your request. The Plan says code 27810-54-LT is not supported by the medical record. The medical 
records don't support that this procedure was performed on the left side. 
 
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 27810-54-LT is  Closed treatment of bimalleolar ankle 
fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli). 
 
 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 code 27810-54-LT. Our reviewer says that code 27810-54-
LT is not supported by the medical record. Our reviewer found the provided records in this case document the 
joint reduction procedure (27810) was performed on the right ankle (not the left).  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 27810-54-LT have not been met. Therefore, we decided that the Plan does 
not have to pay for code 27810-54-LT billed for date of service February 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closure of an enterostomy, large or small intestine; with 
resection and anastomosis other than colorectal (44625) by an assistant-at-surgery, provided on December 29, 
2022. 
 You asked the Plan to pay for an outpatient procedure. You say that you are requesting reconsideration. You 
also say you should be paid for the services provided during the surgery. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for approval of the assistant-at-surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that claims are paid for procedures with specific 
modifiers and only if the services of an assistant-at-surgery are authorized.  
 
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 an outpatient procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that procedures billed with the assistant-at-surgery physician 
modifiers -80, -81, -82, or the AS modifier for physician assistants, nurse practitioners and clinical nurse 
specialists, are subject to the assistant-at-surgery policy. Accordingly, pay claims for procedures with these 
modifiers only if the services of an assistant-at-surgery are authorized. No authorization was found on file for 
an assistant at surgery. The review has determined that there was no documentation provided indicating that the 
assistant at surgery was medically necessary. The assistant at surgery did not meet criteria for approval based 
on the Medicare rules above. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for closure of an enterostomy, large or small intestine; with resection and anastomosis 
other than colorectal (44625) by an assistant-at-surgery, provided on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99307 billed for date of service March 29, 2023. 
 
You asked the Plan to pay for code 99307. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the service at issue was not billed with the required modifier to allow separate 
payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 10060 
provided on March 22, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for code 99307 billed for date of service 
March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the requested services. You say that the testing will clarify treatment. The 
Plan denied your request. The Plan says the test is not an approved test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at, the file, and Medicare rules. The documentation does not show that the testing has been 
approved by the FDA or cleared as a companion diagnostic. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 19, 2023. 
 
You asked the Plan to pay for the medical services. You say that the medical records support the diagnoses 
billed. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that J69.0 has an Excludes1 note in relation to J81.0. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on March 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 24, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not order the 
ambulance, and you told the facility you would not pay for it. 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 ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ambulance 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 ambulance 
services provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 05, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you have been told that the 
provider is in-network. 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 $65 
copayment for out-of-network provider and professional services provided in a primary care provider (PCP) 
office. 
 
You have been asked to pay a $65 copayment for an office visit. This item/service falls within the out-of-
network provider and professional services provided in a primary care provider (PCP) office 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 an office visit provided on April 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intradialytic parenteral nutrition (IDPN). 
 
You asked the Plan to pre-approve the intradialytic parenteral nutrition (IDPN). You say that the service is 
medically necessary. The Plan denied your request. The Plan says records show a functioning gastrointestinal 
tract. 
 
The Plan follows Medicare rules. Medicare rules say that for parenteral nutrition to be considered reasonable 
and necessary, the treating practitioner must document that enteral nutrition (EN) has been considered and 
ruled out, tried and been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. The 
beneficiary must have (a) a condition involving the small intestine and/or its exocrine glands which 
significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a 
motility disorder and impairs the ability of nutrients to be transported through and absorbed by the 
gastrointestinal (GI) system. 
 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 intradialytic parenteral nutrition 
(IDPN). Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
provided documentation does not describe that enteral nutrition had been considered and ruled out, tried and 
been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. 
 
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 intradialytic parenteral nutrition (IDPN) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the intradialytic parenteral nutrition (IDPN).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) provided on April 
3, 2023, by an OON provider.   
You asked the Plan to pay for the medication assisted treatment. 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 the medication assisted treatment (G2067) 
provided on April 3, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 22, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that M47.816 has an Excludes1 note in relation to G54.6. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on February 22, 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 will  will receive maximum results at an IRF. 
The Plan denied your request. The Plan says your records do not show that you have complex rehabilitation 
needs that require frequent evaluation by a rehabilitation physician. The Plan says that the services needed may 
be provided safely in a lower level of care  
 
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 your nursing, medical and rehabilitation needs 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: 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 need rehabilitation, you are unable to walk or 
stand, and need physical and occupational therapy. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the Medicare guidelines.  The Plan says that the services needed may be provided 
safely in a lower level of care.  
 
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 your nursing, medical and rehabilitation needs 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: 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 will benefit from acute rehabilitation to 
optimize the level of functioning prior to returning home. The Plan denied your request. The Plan says the 
enrollee's condition does not meet the Medicare guidelines.  The Plan says that the services needed may be 
provided safely in a lower level of care.  
 
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.  
 
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: 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 a lower level of care inappropriate for the enrollee to 
return home at full capacity needing IRF. The Plan denied your request. The Plan says the enrollee's records do 
not show you need an intensive team for your care. The Plan says that the services needed may be provided 
safely in a lower level of care.  
 
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.  
 
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.