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 enrollee has rehabilitation goals and medical 
complications that cannot be sufficiently met at a lower level of care. The Plan denied your request. The Plan 
says the enrollee does not meet the 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 that the enrollee continues to receive acute care services, and these have not been 
denied. The record indicates that the enrollee has ongoing acute medical issues and still requires acute care 
services before transitioning to 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) provided on May 21, 
2022. 
 
You asked the Plan to pay for the shingles vaccine. You say that this is preventive. The Plan denied your 
request. The Plan says the shingles vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) 
provided on May 21, 2022.  
 
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
services in 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 clinical documentation does not completely specify functional impairments 
or any active medical comorbidities. Thus, the complexity of the enrollees documented nursing, medical, and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. Clinical documentation does not show that the enrollee would require or 
tolerate an intensive rehabilitation regimen.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (81317, 81319) provided December 31, 2022.

You asked the Plan to pay for the genetic testing. You say that the enroll physician ordered genetic testing for the enrollee due to its validated clinical utility clarifying disease risk. The Plan denied your request. The Plan says the records do not show that the enrollee meets the Medicare criteria as the enrollee does not have a cancer diagnosis.

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. There is no documentation that the enrollee has colorectal cancer or signs and symptoms of disease. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing (81317, 81319) provided December 31, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an out-of-network office visit provided on September 26, 2022. 
 
You asked the Plan to pay for an out-of-network office visit. You say that you have a prior authorization for 
these visits, and they should be totally covered. The Plan denied your request. The Plan says that they did not 
address this issue. 
 
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. you have a prior authorization for these visits. The Plan has not addressed this 
issue. Therefore, we decided that the Plan has to pay for an out-of-network office visit provided on September 
26, 2022.  
 
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 genetic testing provided on October 9, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 8135, 81334, 81314, and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 9, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 8135, 81334, 
81314, and 81345.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99204-25 provided on July 14, 2022. 
 
You asked the Plan to pay for procedure code 99204-25. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered 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, the CPT Code Manual definition of 
code 99204 is Office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and moderate level of medical decision making. 
When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter. 
 
We find that CPT code 99204 is supported in the medical record. Specifically, the records document that an 
office visit for the evaluation and management of the enrollee included a medically appropriate examination 
and moderate level medical decision making on July 14, 2022, the same day as the shaving of epidermal or 
dermal lesion (11311) provided by the same provider. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99204-25 have been met. Therefore, we decided that the Plan has to pay 
for procedure code 99204-25 provided on July 14, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
January 27, 2023. 
 
You asked the Plan to pay for the determination of refractive state. You say that you thought this exam would 
be covered. The Plan denied your request. The Plan says you had a medical eye examination office visit on this 
date of service. The Plan also says that coverage of this service was properly denied. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is provided with a routine eye exam 
 
We looked at the file and the Plan's rules. The record shows that this claim was billed with a medical diagnosis 
of Combined forms of age-related cataract, bilateral, and this was not a routine exam that you received. Based 
on this information, we decided that the Plan's rules for coverage of the determination of refractive state have 
not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state 
(92015) provided on January 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each radition therapy visit provided on 
January 17, 2023, to February 15, 2023. 
 
You asked the Plan to waive the copayment for each radition therapy visit. You say that you are disputing the 
share cost. 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 $60 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $60 copayment for each radition therapy visit. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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 each radition therapy visit provided on January 17, 2023, to February 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions and alveoloplasty (41899). 
 
You asked the Plan to pre-approve the extractions and alveoloplasty. You say that the services are medically 
necessary. The Plan denied your request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare.  Therefore, we decided that the Plan does not have to pre-approve the 
extractions and alveoloplasty (41899).
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 facility you want to go to does not accept patients 
once they go home. The Plan denied your request. The Plan says your records do not show your rehabilitation 
needs are complex. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
December 20, 2022. 
 
You asked the Plan to pay for the dental service. You say that you never requested or wanted the dental x-ray 
just a regular cleaning is all you requested to be done. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of November 23, 
2021. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) 
provided on December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for date of service 
January 23, 2023. 
 
You asked the Plan to pay for procedure codes 88342 and 88341. You say that the medical records support the 
billing of these codes. The Plan denied your request. The Plan says payment for codes 88342 and 88341 are 
bundled into payment for code 88360. 
 
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 
88342 and 88341 are column II codes to column I code 88360. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met.  Therefore, we decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for 
date of service January 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
as they have had 3 falls in the past week, are not mobile and have a broken humorous. The Plan denied your 
request. The Plan says the services the enrollee needs can be provided safely in another setting such as a skilled 
nursing facility, home with home health services or home with outpatient therapy.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 64447 billed for date of service November 30, 2022. 
 
You asked the Plan to pay for procedure code 64447. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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 code 64447 
is a column II code to column I code 01402; however, 64447 was billed with a modifier. 
 
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 procedure code 64447. Our reviewer says that procedure 
code 64447 meets criteria for payment. Our reviewer found that the provided medical documentation does 
support the use of procedure codes 64447-59 and 01402. The medical documentation shows that the provider 
performed a nerve block (64447) as well as anesthesia (01402) for the procedure to help with pain during and 
after the surgery. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64447 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 64447 billed for date of service November 30, 2022.  
 
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.