Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 5 additional PT visits. We decided that the Plan does not have to 
pre-approve the remaining 5 PT visits.  
 
You asked the Plan to pre-approve 10 additional physical therapy (PT) visits. You say that the additional PT 
visits are necessary for your recovery process. The Plan says that you do not meet the criteria for the additional 
PT visits. 
 
We decided that the Plan has to pre-approve 5 additional PT visits and does not have to pre-approve the 
remaining 5 visits.  
 
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 item/service at issue. Our reviewer 
says that 5 additional visits are medically necessary. Our physician reviewer found that you have been 
receiving physical therapy. Your motor strength and range of motion are noted to have improved as well as 
your ability to perform daily activities and pain level. You would benefit from 5 additional PT visits to 
maximize your improvement in range of motion and transition to a home exercise program. Therefore, we 
decided that the Plan has to pre-approve 5 additional PT visits and the remaining 5 visits are denied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 additional PT visits have been met. Therefore, we decided that the Plan has to 
pre-approve 5 additional PT visits and does not have to pre-approve the remaining 5 visits. 
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you strongly disagree with the denial and feel the 
patient meets the Medicare criteria for and will benefit from inpatient rehabilitation. You also say that this 
cannot be accomplished if the patient is placed at a lower level of care. The Plan denied your request. The Plan 
says based on the available information, an IRF admission is not reasonable and 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 the enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  Our reviewer also found that the enrollees care needs can be met 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: 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 based on the documentation provided, coverage 
criteria has not been met. The Plan denied your request. The Plan says the services are 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 the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the air ambulance transportation 
provided on December 14, 2022, to December 15, 2022. 
 
You asked the Plan to increase the reimbursement for the ambulance transportation. You say that you were told 
that this service would be fully reimbursed. The Plan denied your request. The Plan says you were reimbursed 
the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance regardless of the number of trips provided by an air ambulance.  
 
 
 The enrollee has been asked to pay $1,239.18, which is 20% coinsurance of the allowed amount for the for the 
ambulance transportation ($6,195.86 allowed amount x 20% = $1,239.18). The record shows the enrollee 
should only be reimbursed $4,958, which is the maximum allowable amount for the ambulance transportation. 
This item/service falls within the ambulance services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to increase the reimbursement for the air ambulance transportation provided on December 14, 2022, to 
December 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips. 
 
You asked the Plan to pre-approve additional trips. You say that due to losing your foot, you require more rides 
to get fitted for the correct prosthetic. You also say that you need another 24 trips to make it to the end of the 
year. The Plan denied your request. The Plan says you have exceeded your benefit limit. 
 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 up to 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The trip log provided in the records shows 
that as of November 8, 2023, you have used 59 of the 60 allowed trips, and have 1 trip remaining. Based on 
this information, we decided that this request exhausts the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wearable defibrillator to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a wearable defibrillator. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested device can be provided by a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a wearable defibrillator to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service April 2, 2023. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the billing of code 99285. 
The Plan denied your request. The Plan says code 99285 is not supported by the medical records because the 
enrollee's presenting problem was not a high/immediate threat to life. As a result, this code was down-coded to 
99284. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 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 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the patient is a 79-year-old male who presented to the 
emergency department with vomiting after failing treatment for the same symptoms as outpatient. Vitals were 
stable. He was treated with Zofran, potassium, and was prepared for upper endoscopy. Although the provided 
documentation included a detailed history and physical, they were not comprehensive. Also, the patient was 
stable hemodynamically and did not require complex workup or treatment. The documentation did not 
sufficiently show medical decision making of high complexity to justify the code, 99285 for this encounter.  
 
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 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service April 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 15, 2021, 
to September 21, 2021, 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 
medical records provide clear documentation of diagnosis J96.01 (acute respiratory failure with hypoxia). The 
Plan denied your request. The Plan says the billed diagnosis of J96.01 (acute respiratory failure with hypoxia) 
is not supported by the medical record. Although the diagnosis is present in the record, reasonable clinical 
evidence to clinically validate the diagnosis is missing. 
 
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 J96.01 (acute respiratory failure with 
hypoxia). 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 J96.01 (acute respiratory failure with hypoxia) is 
not supported by the medical record. Our physician reviewer found the patient is a 91-year-old female who 
presented to the hospital with nausea, vomiting, diarrhea, weakness and wheezing. There was no report of 
shortness of breath, respiratory distress, or hypoxia. SpO2 was normal on low dose oxygen support, and the 
patient was diagnosed with aspiration pneumonia and was treated with antibiotics. The provided documentation 
did not include an arterial blood gas to show supportive evidence of the patient having acute respiratory failure. 
Therefore, the code J96.01 (acute respiratory failure with hypoxia) is not supported in the provided 
documentation 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 15, 2021, to September 21, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 28, 2022, to 
August 31, 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 
medical records support the original DRG billed. The Plan denied your request. The Plan says the diagnosis of 
Sepsis, unspecified organism (A41.9) is not supported by the medical records. Although this diagnosis is 
reported, reasonable clinical evidence within the health record is not present to clinically validate this 
diagnosis. 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 Sepsis, unspecified organism 
(A41.9). 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 Sepsis, unspecified organism (A41.9), is not 
supported in the medical record. Our physician reviewer found the patient is a 90-year-old male who presented 
to the hospital with dyspnea, diaphoresis, and lower extremity swelling/rash. He was diagnosed with cellulitis 
and pneumonia and was started on fluids and antibiotics. He was evaluated and found to have fever but normal 
blood pressure and no hypoxia on room air. Workup also revealed normal platelets, normal creatinine, normal 
bilirubin, no oliguria, and normal mental status. However, the patient did not meet Sepsis 3 criteria without a 
Sequential Organ Failure Assessment (SOFA) score of 2+ and insufficient evidence to support organ failure 
directly related to a dysregulated response to systemic infection. Therefore, the documentation does not support 
the diagnosis code A41.9, Sepsis.  
 
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 August 28, 2022, to August 31, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you are still on oxygen 100% 
of the time and you still work outside of the home. You say that you have to go pick up oxygen tanks because 
you go through 10 per week.  The Plan denied your request. The Plan says the preferred portable oxygen 
concentrator brand is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome.  
 
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 a portable oxygen concentrator. Our 
reviewer says that a portable oxygen concentrator is not medically necessary. Our physician reviewer found 
that you have already been approved for a standard portable oxygen concentrator which is comparable to the 
requested brand specific item. Also, there is no specific clinical indication for the requested brand of portable 
oxygen concentrator. Therefore, the requested equipment is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided May 25, 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 services 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 99215 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is 
spent on the date of the encounter. 
 
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 this date describes the enrollee as reporting shortness of breath which is chronic, but waxes and wanes 
related to allergic rhinitis. The enrollee is on bilevel positive airway pressure (BiPAP) at home. The history and 
physical were appropriate. The enrollee had stable vitals on room air and exam did not reveal any acute 
abnormality. The Plan included continuing BiPAP at home, but no other changes. Based on the stability of the 
enrollee and no change in treatment there was insufficient support of a high level of medical decision making 
to justify the code, 99215. Therefore, this code is not supported for this date.  
 
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 the office visit (99215) provided May 25, 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 requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  The enrollees care needs can be met 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 facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 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 the injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documented physical exam evidence that the facet joints are the cause of pain. 
Therefore, the criteria for coverage have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection (20551) provided on July 13, 
2023. 
 
You asked the Plan to waive the copayment for the injection. You say that you should not be responsible for 
this copayment. 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 each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $250 copayment for the injection. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities 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 injection (20551) provided on July 13, 2023.