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

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay on August 10, 
2022.  
 
You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that the don't feel that the 
cost share is appropriate for the procedure. 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. Cost sharing is charged for each inpatient stay.  
 
 
 You have been asked to pay a 20% coinsurance 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, the total amount you owe is $2,407.72, which is less than 20% coinsurance of 
the allowed amount. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
inpatient hospital stay on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 57 units of procedure code 00630 rendered on January 17, 
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 billed anesthesia time of 57 minutes. 
 
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 00630 is "Anesthesia for procedures in lumbar region; 
not otherwise specified." 
 
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 based on Medicare coding and 
payment standards, the anesthesia service reported (code 00630) is inconsistent with the surgical procedure(s) 
reported by the surgeon and/or the facility. CPT 01941 describes anesthesia for percutaneous image-guided 
neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord (5 
Base units). This CPT code appears to be appropriate. In this case, the medical records submitted with the 
appeal do not support the correct CPT code nor the correct total units billed on the original claim form. 
 
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 57 units of procedure code 00630 rendered on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a third level of an injection provided on August 8, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no unique circumstance for additional levels provided. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the provider did not provide evidence of unique circumstances for a third level facet 
joint injection with sufficient documentation of medical necessity on appeal. Two levels were approved by the 
plan. The review has determined that the documentation does not sufficiently demonstrate a reasonable 
indication for the additional levels. 
 
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 a third level of an injection provided on August 8, 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's current condition, functional deficits, 
and multiple comorbidities, meets full Inpatient Acute Rehabilitation criteria The Plan denied your request. The 
Plan says the records do not show the enrollee's rehabilitation needs are complex. The Plan says services may 
be provided at 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. The medical 
records support 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. It 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: 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 does not meet Medicare guidelines for 
medical necessity because the current medical condition requires further evaluation and treatment in the acute 
care hospital. The Plan denied your request. The Plan says admission is medically necessary for the enrollee.  
 
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 medical 
records support 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. It 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: 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 admission is medically necessary. The Plan 
denied your request. The Plan says the records do not show that the enrollee has a medical need for an IRF 
admission.  
 
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: 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 nursing facility did not do anything for you and 
you need intense rehabilitation. The Plan denied your request. The Plan says that you can receive the necessary 
care 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that you 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 additional trips for routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. The Plan denied your request. The Plan 
says  
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 36 additional trips for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 provided June 15, 2023, through June 
16, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate 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 patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 service. Our reviewer found the provided documentation 
from these dates describe the enrollee with metastases to the brain causing symptoms. There was no progress 
note dated June 15, 2023, with detailed history and examination and medical decision making of high 
complexity to support the code 99232 from this date. A progress note from June 16, 2023, however, was 
provided and included an expanded focus history, expanded focus examination, and medical decision making 
of moderate complexity (dehydration, cancer, improving kidney function, improving encephalopathy) which 
also does not support the code, 99232.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99232 provided June 15, 2023, through June 16, 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 a cancer patient and very week, and you 
were told an IRF admission would help them. The Plan denied your request. The Plan says your ongoing 
skilled therapy and nursing needs can be provided in the current skilled nursing facility (SNF) setting.  
 
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 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. Your require 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 you 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 Orthoptic vision therapy. 
 
You asked the Plan to pre-approve Orthoptic vision therapy. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 Orthoptic vision therapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has history of traumatic brain injury with intermittent alternating 
esotropia and binocular suppression. Orthoptic vision therapy is medically necessary for treating convergence 
insufficiency. All other diagnosis, to include intermittent esotropia, is considered experimental or 
investigational, thus, not medically necessary. Therefore, the enrollee does not meet criteria for the requested 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 Orthoptic vision therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Orthoptic vision therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy services provided on 
July 13, 2023, to August 09, 2023. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that you are requesting 
reconsideration of the copayments applied to the claim. 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 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for the physical therapy services. This item/service falls within 
the outpatient rehabilitation 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 physical therapy services provided on July 13, 2023, to August 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient or observation care (99232-
24) provided July 10, 2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Code 99232-24 for date of service 
July 10, 2023, billed by the provider denied due to being bundled as part of the global surgical fee because it 
was reported on the same date of service as the major surgical procedure, 47800 (Reconstruction, plastic, of 
extrahepatic biliary ducts with end-to-end anastomosis) that was billed for the same date of service by two 
different providers and both providers were billed under the same billing groups National Provider Identifier 
(NPI). A modifier was not billed on the claim to represent the E&M services is separately reportable with 
major surgical procedure and the decision for Surgery was taken in this E&M visit. Therefore, we decided that 
the Plan does not have to pay for the subsequent hospital inpatient or observation care (99232-24) provided 
July 10, 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 services are medically necessary for the enrollee. 
The Plan denied your request. The Plan says The required services can be provided in an alternate setting.  
 
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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies. 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.