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 you need the rehab to get stronger and to walk better. 
The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements 
for approval. 
 
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. 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 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 you 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 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's needs are unable to be met at a lower 
level of care. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
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 
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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Pigmented Lesion Assay testing (0089U) provided on 
October 5, 2022. 
 
You asked the Plan to pay for PLA testing. You say that this is a covered test which was ordered by the 
enrollee's physician and was reported correctly. The Plan denied your request. The Plan says there is 
insufficient documentation to support that the criteria for medical necessity are met in this case. 
 
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 PLA testing have been met. 
Specifically, there is no specific documentation of the lesion which was biopsied for this test in this case. 
Without this documentation, it cannot be verified that the criteria for medical necessity of this test are met. 
Therefore, we decided that the Plan does not have to pay for Pigmented Lesion Assay testing (0089U) provided 
on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service January 11, 
2023.   
You asked the Plan to pay for procedure code 99232. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says 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 99232 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not 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 99232 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99232 billed for date of service January 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on December 16, 2022, billed 
with procedure codes 74230-26, 74240-26, 72040-26, 70100-26, and 70310-26. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. As such, this is a non-covered service. Therefore, 
we decided that the Plan does not have to pay for radiological services provided on December 16, 2022, billed 
with procedure codes 74230-26, 74240-26, 72040-26, 70100-26, and 70310-26.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99223) provided on December 26, 2022. 
 
You asked the Plan to pay for hospital care. You say that this claim was submitted with valid diagnosis codes. 
The Plan denied your request. The Plan says this claim was submitted with two diagnosis codes which cannot 
be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition 
together with the condition with the note. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hospital care have not been met. Specifically, this claim was submitted with diagnosis codes 
R06.89 (other abnormalities of breathing) and J96.90 (respiratory failure, unspecified, unspecified whether 
with hypoxia or hypercapnia). However, R06 codes have an Excludes1 note with codes within the J96 code set. 
This means that it is generally not appropriate to report these two diagnoses together. Therefore, we decided 
that the Plan does not have to pay for hospital care (99223) provided on December 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (G0277, 99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that hyperbaric oxygen therapy is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says hyperbaric oxygen therapy is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve hyperbaric oxygen therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the review indicates that the enrollee has radiation cystitis. There is no 
documentation of conventional treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy (G0277, 99183).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 21, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. 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 21, 2023, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87653 and 87798 billed for date of service 
December 15, 2022. 
 You asked the Plan to pay for procedure codes 87653 and 87798. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says payment for codes 87653 and 87798 is included in 
the payment for codes 87150 and 87801. 
 
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 87653 and 87798 are column II codes to column I codes 87150 and 
87801; however, 87653 and 87798 were 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 codes 87653 and 87798. Our reviewer says that 
procedure codes 87653 and 87798 do not meet criteria for payment. Our reviewer found that the provided 
documentation does not support that procedures 87653 and 87798 were separately performed and distinct from 
procedures 87150 and 87801. 
 
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 codes 87653 and 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87653 and 87798 billed for date of service December 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 8, 2022, to 
November 15, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that the member was seen in a nursing facility and 
feel 
that an authorization would not have been required. 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 nursing facility care provided on November 8, 
2022, to November 15, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 24, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 January 24, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on January 02, 2023. 
 
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. 
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 wound care services 
provided on January 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the biopsy provided on March 06, 2023. 
 
You asked the Plan to reduce the copayment for the biopsy. You say that you should only have an office visit 
copayment for this date. 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 $350 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $350 copayment for the biopsy. This item/service falls within the in-network 
outpatient surgery 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. The records show the procedure was provided at an outpatient hospital and the copayment was applied correctly. Therefore, we decided that the Plan does not have to reduce the copayment for the biopsy 
provided on March 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic hearing exam provided on 
April 06, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic hearing exam. You say that you do not know 
why you have a copayment for this service. 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 $35 
copayment for in-network hearing services. 
 
You have been asked to pay a $35 copayment for the diagnostic hearing exam. This item/service falls within 
the in-network hearing 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 diagnostic hearing exam provided on April 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on  
October 26, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says medical nutrition therapy (MNT) is covered by 
Medicare only for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospitalist physician visit provided on December 29, 2022. 
 
You asked the Plan to pay for physician visit. You say that procedures rendered at an inpatient facility are a 
covered benefit. The Plan denied your request. The Plan says this claim was not billed with the appropriate 
Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that evaluation and management services rendered to 
an enrollee who is a registered inpatient or outpatient of a hospital must use a Place of Service (POS) code reflecting the appropriate inpatient hospital POS or outpatient hospital POS regardless of where the face-to-
face service occurs.  
 
We looked at the file and Medicare rules. This claim was billed with POS code 21, reflecting a hospital 
inpatient POS. However, the enrollee was a hospital outpatient at the time of service, so POS code 21 would 
not be appropriate. Based on this information, we decided that Medicare rules for coverage of physician visit 
have not been met. Therefore, we decided that the Plan does not have to pay for a hospitalist physician visit 
provided on December 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on January 13, 2023. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you say you were never advised you 
would have a copay. 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 $350 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $350 copayment for colonoscopy. This item/service falls within the outpatient 
hospital observation 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 colonoscopy 
provided on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care treatment provided on November 28, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for wound care treatment. You say that the assisted living facility is responsible to 
obtain prior authorization for all of their patients. 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 wound care treatment provided on November 28, 
2022, by an out-of-network (OON) provider.