Persius/hicric huggingface dataset:
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 requested IRF services are necessary for you to 
regain your strength before returning home. You also say you are weak and a fall risk. The Plan denied your 
request. The Plan says admission to an IRF is not reasonable and necessary, as your condition does not meet all 
the Medicare rules.  
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical therapy and/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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93621, 76937) provided on September 1, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the add-on codes 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. In this case, we have confirmed that codes 93621 and 76937 are add-on codes and have not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the services (93621, 76937) provided on September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on March 15, 2023, billed with 
codes 87481, 87798 and 87801. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on March 15, 2023, billed with codes 87481, 87798 and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the ophthalmic scan provided on August 
7, 2023, by an OON provider.  
 
You asked the Plan to pay for the office visit and the ophthalmic scan. You say that you are requesting 
reconsideration of the denied claim. 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 the office visit and the ophthalmic scan provided 
on August 7, 2023, by an OON provider.
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 has not been able to get regular therapy 
services at home and is becoming increasingly weaker. You also say the enrollee requires, and has the potential 
for, significant improvement with consistent intensive therapy under the oversight of the multidisciplinary team 
to ensure optimal recovery and prevent further decline. The Plan denied your request. The Plan says the notes 
do not show that the enrollee's are specifically requires the involvement of a doctor in the field of 
Rehabilitation Medicine, that the enrollee has complex care needs that require a coordinated team approach or that the enrollee must have an intensive therapy program (3 hours a day, at least 5 days a week) in order to 
improve self-care functioning.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets medical necessity defined by 
Medicare guidelines for admission to an IRF. The Plan denied your request. The Plan says criteria for 
admission to the acute inpatient rehabilitation setting have 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 is unable to rehabilitate their left shoulder currently. The enrollee does 
not require intensive rehabilitation services and does not require frequent physiatry oversight.  
 
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 the emergency department visit (99285) provided July 6, 
2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 vitals were stable, abdominal was mildly tender, no rebound/guarding. Constipation was suspected. The history was detailed, but not 
comprehensive and the examination was an expanded focus, not comprehensive in the provided documentation. 
Labs were unremarkable. The enrollee was stable. The documentation did not support medical decision making 
of high complexity.  
 
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 emergency department visit (99285) provided July 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0425, A0429) provided on May 
29, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed modifier is 
not appropriate. 
 
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 payment for CPT codes A0425 and A0429 is not supported in the medical record. Specifically, 
these codes were billed with modifier SS in this case. As the records show that the enrollee was transported 
from a hospital to a mental health facility, the use of modifier SS is not appropriate. 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 ambulance services (A0425, A0429) provided on May 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 20, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically 
necessary at the acute level of care. You also say that you would like the denial to be overturned. The Plan 
denied your request. The Plan says the clinical information does not support a reasonable expectation that the 
enrollee would require hospital services extending beyond 2 midnights. 
 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee did not have another episode or unstable vitals or medical condition that 
would warrant hospital care lasting 2 midnights. The enrollee would not have likely had an adverse event if not 
admitted.  
 
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 have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided May 24, 2023, 
through May 25, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were provided to the 
enrollee in good faith, and you would like this claim to be reprocessed and paid based on the medical necessity 
of the enrollee's visit. The Plan denied your request. The Plan says the clinical does not support a reasonable 
expectation that the enrollee would require hospital services extending beyond 2 midnights.  
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was otherwise hemodynamically stable, and it was not expected that the 
enrollee would require hospital care that would likely cross 2 midnights. The documentation did not suggest an 
increased risk of adverse event if not admitted.  
 
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 have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided May 24, 2023, through May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for travel expenses incurred on June 7, 2023. 
 
You asked the Plan to pay for travel expenses. You say that your hernia occurred because of your transplant so 
travel for care should be covered. The Plan denied your request. The Plan says this travel was not for transplant 
services and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which a Medicare 
Advantage (MA) plan provides transplant services at a more distant location, the MA plan must provide 
reasonable transportation for the enrollee and a companion to the distant facility, and provide reasonable 
accommodations for the enrollee and a companion while in the distant location for medical care. 
 
We looked at the file and Medicare rules. The travel at issue was not for transplant services. Based on this information, we decided that Medicare rules for coverage of travel expenses have not been met. Therefore, we 
decided that the Plan does not have to pay for travel expenses incurred on June 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided March 
15, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that please see the attached medical 
records. The Plan denied your request. The Plan says based on Medicare guidelines, the ultraviolet (UV) 
phototherapy wand requested does not meet the requirements for approval. 
 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 record does not show a diagnosis of psoriasis. There is also no 
indication that intractable psoriasis, as there is no indication the enrollee has failed other treatments for 
psoriasis. There are also no other factors described that would justify treatment at home rather than alternative 
sites, like a clinic or the hospital. Based on this information, we decided that Medicare rules for coverage of the 
ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pay for 
the ultraviolet light therapy system (E0691) provided March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140) and the endodontic 
therapy (D3320) for tooth #13 provided by an out-of-network provider on July 10, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the Plan must reimburse you 80% of the 
service cost. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. Also, the 
correct cost share was applied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The total amount billed for the limited oral evaluation (D0140) was $75 and the total allowed amount was $30 
leaving a difference of $45 ($75 billed - $30 allowed). The total coinsurance amount was $6 ($30 allowed x 
20% coinsurance). The total liability you have for the limited oral evaluation was $51 ($45 difference + $6 
coinsurance). The total amount billed for the endodontic therapy (D3320) was $750 and the total allowed 
amount was $395 leaving a difference of $355 ($750 billed - $395 allowed). The total coinsurance was $79 
($395 allowed x 20% coinsurance). The total liability you have for the endodontic therapy was $434 ($355 
difference + $79 coinsurance). 
 
You have been asked to pay a 20% coinsurance and the difference between the out-of-network providers 
charges and the Plans payment. 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 pay more for a limited oral evaluation 
(D0140) and the endodontic therapy (D3320) for tooth #13 provided by an out-of-network provider on July 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 13, 2023. 
 
You asked the Plan to pay for the office visit. You say that the referral is attached to support that the service 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on February 27, 2023, billed 
with codes 87653, 87798 and 87481. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on February 27, 2023, billed with codes 87653, 87798 and 87481.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing of 22 or more drug classes (G0483) provided 
on January 24, 2023. 
 
You asked the Plan to pay for the definitive drug testing of 22 or more drug classes. You say that this testing 
was medically necessary. The Plan denied your request. The Plan says that this claim was billed incorrectly. 
 
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 G0483 is definitive drug testing of 22 or more classes. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the record shows that 22 drug 
classes were tested. Based on this information, we decided that Medicare rules for coverage of the definitive 
drug testing of 22 or more drug classes have been met. Therefore, we decided that the Plan has to pay for the 
definitive drug testing of 22 or more drug classes (G0483) provided on January 24, 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.