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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says according to the available records, the member does not meet all the required Medicare 
criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show you need for an intensive team 
(rehab doctor and nurse, social worker, and therapists) for care. Services needed may be provided safely in a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99284) provided on October 13, 
2022. 
 
You asked the Plan to pay for emergency room visit. You say that the enrollee was seen by the emergency 
department for a medically necessary procedure. The Plan denied your request. The Plan says surgical 
procedure 10061 has a global value of 010 and 99284 was not billed with an appropriate modifier for separate 
payment. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient. 
 
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 emergency room visit. Our reviewer says that this code does 
not meet criteria for payment. Our reviewer found medical records support an emergency department visit 
which resulted in an incision and drainage procedure. The claim denied correctly, because there is a global 
period for incision and drainage, an appropriate modifier would need to be appended to evaluation and 
management service. CPT and Medicare reimbursement rules allow the reporting of an evaluation and 
management service when the service is either a significant, separate service or leads to the decision to operate 
or perform a procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of emergency room visit have not been met. Therefore, we decided that the Plan 
does not have to pay for an emergency room visit (99284) provided on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on March 8, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a home visit. You say that services were provided in good faith and were 
medically necessary. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a home visit provided on March 8, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio lancets and test strips at the quantity of 
200 test strips per 50 days (to allow for 4 times daily testing).  
 
You asked the Plan to pre-approve the requested amount of test strips. You say that this quantity is required for 
testing four times per day. The Plan denied your request. The Plan says the request exceeds the quantity 
limitation.  
 
The Plan follows Medicare rules. Medicare rules say that for enrollees using insulin, more than 300 test strips 
per 90 days can only be covered if there is clear evidence in the records showing that the number of tests per 
day is medically necessary to improve glycemic control. 
 
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 requested amount of test strips. Our 
reviewer says that the number of test strips being requested in this case is not shown to meet coverage criteria.  
Our physician reviewer found the provided records in this case do not support the need for the quantity 
requested. Records do not indicate the enrollee is testing his glucose level more than 2 or 3 times daily. As such, the number of test strips requested exceeds the medical need.  
 
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 requested amount of test strips have not been met. Therefore, we decided 
that the Plan does not have to pre-approve OneTouch Verio lancets and test strips at the quantity of 200 test 
strips per 50 days (to allow for 4 times daily testing).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 1, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you did not realize you were not in-network. The 
Plan denied your request. The Plan says this was not authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 1, 2023, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
11, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not ask to be 
taken to the emergency room. 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 $270 
copayment for ambulance services.  
You have been asked to pay a $270 copayment for the ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
services provided on April 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary.  
 
Our physician reviewer found the documentation available for review doesnt support that you require 
additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. 
You do not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or 
services in order to improve your condition, perform a maintenance program to maintain your condition and/or 
prevent deterioration. There is not a signed plan of care established by a physician. The requested home health 
services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on July 28, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that you should be considered in-network because 
you participate in Medicare. The Plan denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on July 28, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary. The 
Plan denied your request. The Plan says you don't meet all the requirements. Services needed may be provided 
safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that you require that are not available at 
the current health care setting being offered by the health plan. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (51595, 51999) provided on July 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
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 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 use of codes 51595 
and 51999 is not supported by the records provided. Our reviewer found that for code 51595, based on the 
medical documentation submitted, the more appropriate code to bill for the service provided on July 13, 2022, 
is CPT 51999 because the procedure was not an open procedure, it was done laparoscopically. For code 51999, 
the medical records provided do not include documentation identifying what the unlisted laparoscopy 
procedure, bladder procedure was that was performed on July 13, 2022, therefore this procedure cannot be verified. 
 
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 the services (51595, 51999) provided on July 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 You asked the Plan to pre-approve Hyalgan. You say that you do not want to use a walker and are unable to 
exercise or swim. You say that your knee gets very painful, and you want to try this drug first before having 
any knee surgery. The Plan denied your request. The Plan says that the step therapy requirements have not been 
met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found that you have not tried and failed the Plan's 
required drugs Monovisc, Orthovisc, Synvisc or Synvisc One. Also, there is no indication that the Plan's 
required drugs would likely be less effective and or likely have adverse effects on you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a trigger point injection provided on February 15, 2023. 
 
You asked the Plan to pay for the trigger point injection. You say that the service was medically necessary. The 
Plan denied your request. The Plan says that diagnosis code M62.838 is not supported as medically necessary 
when billed with CPT code 20552 per the Medicare Local Coverage Article A57751 or the Medicare Local 
Coverage Determination L35010. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a coding rule or a valid Medicare rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for a trigger point injection provided on 
February 15, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 28, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on February 28, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
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. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023 to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023 to February 25, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary.  
 
Our physician reviewer found the documentation doesnt support that the enrollee requires additional skilled 
nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does 
not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in 
order to improve the enrollees condition, perform a maintenance program to maintain the enrollees condition 
and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of 
chronic medical problems or hospitalizations. The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.