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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a good candidate for IRF services.  
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 
an IRF. 
 
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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of an upper joint 
extremity. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support medical necessity. 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 MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found bilateral shoulder x-rays have been done but 
there is no physical exam of the left shoulder and in particular no provocative maneuvers.  No red flag is 
presented.  Without such a red flag the medical necessity of MRI left shoulder without a trial of 6 weeks of 
physical therapy has not been established in the records provided. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of an upper joint extremity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided from September 30, 2022, to 
October 2, 2022. 
 
You asked the Plan to pay for procedure code 99233. The Plan denied your request. The Plan says procedure 
code 99233 is not supported by the medical records submitted. 
  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure code 99233 have been met. 
Specifically, the medical records submitted do not verify procedure code 99233 was provided on each date of 
service at issue. Therefore, we decided that the Plan does not have to pay for procedure code 99233 provided 
from September 30, 2022, to October 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 14, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have provided records to show the medical 
necessity of these services. The Plan denied your request. The Plan says you billed these services with a 
modifier that makes the claim not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all claim line(s) items submitted with a GZ 
modifier shall be denied automatically and will not be subject to complex medical review. 
 
In this case, you billed the services in dispute with the GZ modifier, so no payment can be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided on February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extracapsular cataract removal procedure with 
insertion of an intraocular lens prosthesis. 
 
You asked the Plan to pre-approve the cataract removal with a lens prosthesis. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that glaucoma surgical aqueous drainage devices are 
covered if all of the criteria listed in the Medicare rules section 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 the cataract removal with a lens 
prosthesis. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the 
enrollee is not currently using a glaucoma/hypotensive eye drop. Additionally, the enrollee's visual acuity is 
20/20 in both eyes, and the cataract procedure would not be considered 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 cataract removal with a lens prosthesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an extracapsular cataract removal procedure with insertion 
of an intraocular lens prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth mental health services provided by a Licensed 
Mental Health Counselor (LMHC) from February 23, 2023, to March 14, 2023. 
 
You asked the Plan to pay for the LMHC services. You say that you did not know that you could no longer see 
an out-of-network mental health counselor. You said that you have been seeing this provider for years and you 
are comfortably with them. The Plan denied your request. The Plan says services with a LMHC are not 
covered.  The Plan also says that telehealth mental health services are not covered with out-of-network 
providers. 
 
The Plan must follow Medicare rules. Medicare rules say that that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  
 
In this case, the provider you saw is a LMHC.  This is not a valid provider type for Medicare.  In addition, your 
Plan contract explicitly states that out-of-network coverage is not available for mental health services delivered 
via telehealth. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LMHC services have not been met. Therefore, we decided that the Plan does not have to pay 
for telehealth mental health services provided by a Licensed Mental Health Counselor (LMHC) from February 
23, 2023, to March 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on October 10, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for genetic testing. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services provided are not a covered benefit. 
 
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 genetic testing provided on October 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get stronger and would benefit from IRF 
services. The Plan denied your request. The Plan says the request 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care from June 20, 2023, 
forward. 
 
You asked the Plan to pre-approve acute inpatient hospital care from June 20, 2023, forward. You say that this 
is medically necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care from June 
20, 2023, forward. Our reviewer says that the documentation does not support that the criteria for inpatient 
admission are met in this case. Our physician reviewer found based on the medical records provided there is no 
documentation that continued inpatient admission from June 20, 2023, forward meets Medicare criteria for 
medically reasonable and necessary. Provided records in this case do not document any medical condition or 
assessment by the treating physician showing that you required medically necessary hospital care that was 
expected to span anymore midnights after June 20, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care from June 20, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care from June 20, 
2023, forward.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 77002 billed for date of service February 1, 2023.  
 
You asked the Plan to pay for procedure code 77002. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 77002 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 77002 have been met. Therefore, we decided that the Plan 
has to pay for procedure code 77002 billed for date of service February 1, 2023.   
 
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 the enrollee requires services in an IRF for their care 
needs and would be expected to make significant improvements. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for admission to an IRF.  
 
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 treatment by multiple therapies. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 3, 2022, to May 
18, 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 DRG as billed. The Plan denied your request. The Plan says billed diagnoses of 
A41.59 (other gram-negative sepsis) and R65.20 (severe sepsis without septic shock) are not supported by the 
medical record. Removal of these diagnoses resulted in a lower DRG being 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 diagnoses of A41.59 (other gram-negative sepsis) 
and R65.20 (severe sepsis without septic shock). 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  diagnoses of A41.59 
(other gram-negative sepsis) and R65.20 (severe sepsis without septic shock) are not supported by the medical 
record. Our physician reviewer found the patient is an 85-year-old male with chronic obstructive pulmonary 
disease on home oxygen and heart failure who presented to the hospital with hypoxia. His workup revealed 
pneumonia which was treated with antibiotics. The patient required oxygen support, however, creatinine, 
platelets, bilirubin were stable/normal, he was alert and oriented, had stable blood pressure, and had no 
reported oliguria. Sepsis 3 criteria was not met. The patient did not have sufficient evidence of a systemic 
dysregulated response to infection leading to significant organ failure that is life-threatening to support the 
diagnosis code, A41.59 (other gram negative sepsis) or R65.20 (severe 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 May 3, 2022, to May 18, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three units of code 87801 billed for May 2, 2022, and 
September 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed units are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 three 
units of code 87801 is not supported by the records provided for the dates of service in question. Our physician 
reviewer found that CPT codes that test for multiple infectious agents are reported with one unit of service if 
one procedure, one methodology, or one test kit is used to perform the test (e.g., 87300, 87451, 87800, 87801). The medical record does not support the units billed. 
 
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 three units of code 87801 billed for May 2, 2022, and September 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on November 28, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that this testing should be paid based on Medicare 
guidelines and enrollee medical necessity. The Plan denied your request. The Plan says the requested testing is 
not covered. 
 
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 requested testing is not covered by Medicare or the Plan. Based 
on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. 
Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on 
November 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
January 10, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the member was seen twice on 
same date of service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on January 13, 2023. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the emergency department visit have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
January 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 22, 2022, to 
March 21, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe this claim should be 
reprocessed. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 22, 2022. The NOA was not received by the Plan until March 28, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 22, 2022, to March 21, 2022.