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

 
We decided that the Plan does not have to pay for procedure code(s) 94726 billed for date of service February 
10, 2023. 
 
You asked the Plan to pay for procedure code(s) 94726. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components are payable when the enrollee is not a patient of any hospital, and the service is received 
in a setting that is not part of a hospital. 
 
The Plan has not submitted evidence that indicates this service was provided to the enrollee while an inpatient 
or outpatient in any hospital. In this case, CPT code 94726 does not need to be billed with a modifier to indicate the professional component only. Based on this information, we decided that Medicare rules for 
coverage of procedure code 94726 have been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 94726 billed for date of service February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the out-of-network cost-sharing for a physician office visit 
(99213) and betamethasone injection (J0702) provided on July 6, 2023. 
 
You asked the Plan to waive the out-of-network cost-sharing for an office visit and a drug injection. You say 
that your regular orthopedic specialist was not available, and you did not realize the substitute specialist was 
out-of-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 Physician/Practitioner services when provided by an out-of-network specialist, and 20% 
coinsurance for Medicare Part B prescription drugs.   
You have been asked to pay a $65 copayment for an office visit provided by an out-of-network specialist. This 
item/service falls within the Physician/Practitioner services benefit category. 
 
You have also been asked to pay $5.57 (20% of the Medicare-allowed charge of $27.84) for a drug injection. 
This item/service falls within the Medicare Part B prescription drugs benefit category. 
 
This means that you have been asked to pay the correct amounts 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 out-of-network cost-sharing for a physician office visit (99213) and 
betamethasone injection (J0702) provided on July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99233 
performed on date of service June 13, 2023. 
 You asked the Plan to pay for 99233. You say that 99233 should be covered as billed because the enrollee was 
provided services by multiple physicians of different specialties on the same date of service. The Plan denied 
your request. The Plan says 99233 is denied because payment for this service is included in payment for the 
minor surgical procedure billed on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that modifier -25 is used to 
report circumstances where the enrollee's condition requires a significant, separately identifiable evaluation and 
management service above and beyond the usual care associated with the procedure that was performed by the 
same provider on the same date. 
 
In this case, we confirmed code 36556 is a minor procedure with a global surgery indicator of 000. We 
confirmed 99233 was billed on the same date of service as 36556 by a physician of the same specialty under 
the same billing group, which is considered the same provider. According to Medicare rules, an evaluation and 
management service billed on the same date as a minor procedure billed by the same provider or a provider of 
the same specialty in the same billing group is only eligible for separate payment if modifier -25 is appended 
and documentation indicates the evaluation and management services were significant and separately 
identifiable. We confirmed that no modifier was billed with 99233 in this case. Based on this information, we 
decided that Medicare rules for coverage of 99233 have not been met. Therefore, we decided that the Plan does 
not have to pay for the evaluation and management services coded as 99233 performed on date of service June 
13, 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 is very weak and can only walk 15 steps 
needing rehabilitation to regain mobility. The Plan denied your request. The Plan says the enrollee's records do 
not show the need to be seen by a rehabilitation physician for complex rehabilitation needs. 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.  
 
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 pay for inpatient hospital services provided on September 11, 2022, 
to September 12, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis of I21.A1 (Myocardial infarction type 2) was coded accurately. The Plan denied your request. The 
Plan says the billed diagnosis of I21.A1 (Myocardial infarction type 2) is not supported by the medical record. 
There were no ischemia-specific symptoms not attributable to other causes, and there were no new ischemic 
changes on electrocardiogram (EKG) or cardiac imaging. As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a diagnosis of I21.A1 (Myocardial infarction type 
2) . 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the diagnosis of I21.A1 (Myocardial infarction type 2)  is not 
supported by the medical record. Our physician reviewer found the patient is an 89-year-old female who 
presented to the hospital with left-sided abdominal pain. Noted in the workup was an elevated troponin which 
was worked up with electrocardiogram (EKG) which revealed no evidence of ischemia. Also, the patient did 
not exhibit any chest pain, shortness of breath, nausea, or vomiting. As the patient did not have sufficient 
evidence of an active acute infarction, the documentation does not sufficiently support I21.A1 (Myocardial 
infarction type 2) for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 11, 2022, to September 12, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
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 IRF services to regain your balance and to 
help you adjust to the loss of vision in your right eye. The Plan denied your request. The Plan says you do not 
meet the requirements 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 your 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (B4185). 
 
You asked the Plan to pre-approve intradialytic parenteral nutrition. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that parenteral nutrition is covered when specific criteria 
are met. 
 
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 intradialytic parenteral nutrition. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not 
meet the criteria for such treatment as there was no reported clinical malabsorption or other non-functioning 
gastrointestinal tract that would warrant parenteral nutrition.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intradialytic parenteral nutrition have not been met. Therefore, we decided that 
the Plan does not have to pre-approve intradialytic parenteral nutrition (B4185).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tyrvaya. 
 
You asked the Plan to pre-approve Tyrvaya. You say that the medication is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tyrvaya.  
 
Benefits for Tyrvaya may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 requires medical management and 
rehabilitation in an inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee's condition 
does not meet all of the requirements for inpatient rehabilitation admission. 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.  
 
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 have not gotten any better with your mobility 
and speech. You say that you can heal better with additional rehabilitation. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary.  
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73562 and 96372 for date of service May 
28, 2023. 
 
You asked the Plan to pay for procedure codes 73562 and 96372. 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 73562 and 96372 are not payable as billed. Specifically, codes 73562 and 96372 have 
a status indicator of Q1. Code 99284 was billed on the same claim, with the same date of service, with a 
revenue code of 450. This gives code 99284 a status indicator of "V". Therefore, codes 73562 and 96372, 
which have a status indicator of Q1, is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 73562 and 96372 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 73562 and 96372 for date of service May 28, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on May 31, 2023, and June 
5, 2023. 
 
You asked the Plan to pay for the psychotherapy services. You say that it is difficult to find a trauma therapist 
without having to tell your whole story all over again, which could re-traumatize you and make your therapy needs longer. The Plan denied your request. The Plan says the supervising provider has opted out of Medicare 
and the provider supplying direct treatment is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. The rules also say that Medicare payment cannot be 
made to a provider that is not enrolled in the Medicare program. A Master of Social Work is not eligible to 
enroll in Medicare. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. This provider states that they were acting as a supervisor to a Licensed 
Master Social Worker (LMSW) who actually provided direct treatment. LMSWs are not eligible to enroll in 
Medicare. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on 
May 31, 2023, and June 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure device 
(LAAC) (33340).  
You asked the Plan to pre-approve placement of a LAAC. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when specific criteria are 
met. 
 
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 placement of a LAAC. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found guidelines would not support 
implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or 
medically necessary in this enrollees 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 placement of a LAAC have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a left atrial appendage closure device (LAAC) (33340).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 9, 2023. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the services at issue have been reported on an incorrect Type of 
Bill. 
 
The Plan must follow Medicare rules. Medicare rules say that that Type of Bill is a required data element. This 
is a 4-digit alphanumeric code that gives two pieces of information. The first three digits indicate the base type 
of bill. The fourth digit indicates the sequence of this bill in this particular period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the Type of Bill reported on the claim at 
issue is not a permitted Type of Bill for home health services. Therefore, we decided that the Plan does not 
have to pay for home health services provided on May 9, 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 LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 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 acute hospital can provide for all the enrollees present inpatient care needs and 
the enrollee is receiving an appropriate level of care in the present setting. The provided records do not explain 
what care services will be provided in the LTACH that are not currently available. The records do not support 
the need to transfer from one acute hospital to another. Continued care in the short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility, or a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.