Persius/hicric huggingface dataset:
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee's clinical needs 
can be met at the current facility.  
 
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 the enrollee has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied by the Plan. The 
medical record does not indicate that the enrollee requires services that they are not currently receiving but that 
would be available at the LTACH facility. 
 
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 procedure codes 99204, 74230, 74230, 72040, 70100, 70310, 
and 71045 for date of service February 14, 2023. 
 You asked the Plan to pay for procedure codes 99204, 74230, 74230, 72040, 70100, 70310, and 71045. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 99204, 74230, 74230, 72040, 70100, 70310, and 71045 are not payable as billed. 
Specifically, these services were billed with a place of service 11 (office). The documentation does not support 
the services were performed in an office or other outpatient setting. The documentation shows that the services 
were provided in a mobile setting at a skilled nursing facility. This means the claim is not payable as billed. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99204, 74230, 
74230, 72040, 70100, 70310, and 71045 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 99204, 74230, 74230, 72040, 70100, 70310, and 71045 for date of service February 
14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on July 21, 2022. 
 
You asked the Plan to pay for the home visit. You say that you are requesting reconsideration for the denied 
claim. 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 home visit provided 
on July 21, 2022.
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 would receive the services needed to become 
stronger and you believe you can do this with physicians who deal with your condition. The Plan denied your 
request. The Plan says you do not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81292, 81301) provided on January 5, 
2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria for the billed codes has 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. 
 
We find that CPT codes 81206, 81292, and 81301 are not supported in the medical record. Specifically, per 
Local Coverage Determination (LCD): Biomarkers for Oncology (L35396) the billed tests are not covered for 
the diagnosis code billed. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81206, 
81292, 81301) provided on January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a breast tomosynthesis and a mammogram 
provided on February 21, 2023. 
 
You asked the Plan to waive the copayments for a breast tomosynthesis and a mammogram. You say that these 
services should be fully covered. 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 $75 
copayment for diagnostic procedures and tests, including ultrasounds. 
 
 
 You have been asked to pay a $52.25 copayment for a breast tomosynthesis. You have also been asked to pay 
$22.76 for the mammogram. You have been asked to pay a total of $75 ($52.25 copayment + $22.76 
copayment = $75). These items/services fall 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 copayments for a breast tomosynthesis 
and a mammogram provided on February 21, 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 to ensure that 
the enrollee receives the services needed to ensure a full recovery. The Plan denied your request. The Plan says 
ongoing skilled care can be provided in an alternative setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 16, 2023, to February 17, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the 
copayment. 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 per day, for days 1 to 6 and a $0 copayment per day, for days 7 to 90 for each Medicare-covered 
hospital stay. 
 
 You have been asked to pay a $270 copayment for day 1 of the inpatient hospital stay. You have not been 
charged for any additional days. This item/service falls within the inpatient hospital care 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 an inpatient hospital stay provided from February 16, 2023, 
to February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walk-in bathtub (A9270) purchased on January 17, 2023. 
 
You asked the Plan to pay for the walk-in bathtub. You say that the enrollee needed this item. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the walk-in bathtub (A9270) purchased on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound debridement provided on April 
17, 2023. 
 
You asked the Plan to waive the copayment for the wound debridement. You say that this was not surgery, and 
on previous dates you did not have a surgery copayment. 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 $370 
copayment for outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $370 copayment for the wound debridement. This item/service falls within the 
outpatient surgery provided at an outpatient hospital 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 record shows this claim was approved and you are 
responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the 
copayment for the wound debridement provided on April 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each spinal injection provided on February 
07, 2023, to March 16, 2023. 
 
You asked the Plan to waive the copayment for each spinal injection. You say that the provider said you had to 
receive the injections. 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 $250 
copayment for in-network outpatient surgery provided at an ambulatory surgical center. 
 
You have been asked to pay a $250 copayment for each spinal injection. This item/service falls within the in-
network outpatient surgery provided at an ambulatory surgical center 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 spinal injection provided on February 07, 2023, to March 16, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobility equipment provided on November 07, 2022. 
 
You asked the Plan to pay for the mobility equipment. You say that your provider ordered this equipment. 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 mobility equipment 
provided on November 07, 2022.
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 you need intensive therapy to help you reach your 
highest practical level and would like to avoid an unnecessary rehospitalization. The Plan denied your request. 
The Plan says you do not meet the Medicare SNF care criteria. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have identifiable skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not 
require skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a skilled nursing facility 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the heart. 
 
You asked the Plan to pre-approve heart CTA. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this scan is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules state that CTA scans may be covered for certain indications. 
 
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 heart CTA. Our reviewer says that the 
enrollee does not meet criteria for this test. Our physician reviewer found this is being requested for general 
examination. There is no clinical evidence to support the medical necessity of this scan or that the enrollee 
meets the Medicare coverage indications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of heart CTA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography angiography (CTA) of the heart.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus and diphtheria toxoids and acellular pertussis 
vaccine (Tdap) vaccine, and administration (90471) provided on March 10, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that you felt you should be up to date with your 
vaccines. You say that when your doctor offered it, you accepted. You also say that you were surprised when 
you received a denial. The Plan denied your request. The Plan says this 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 vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the Tetanus and diphtheria toxoids and 
acellular pertussis vaccine (Tdap) vaccine, and administration (90471) provided on March 10, 2023.  
 
Benefits for the vaccine services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 billed for 
February 1, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 96365, 96366, 96521, and J1817 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. 
 
In this case, the CPT Code Manual definition of code 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is refilling and maintenance 
of portable pump. The definition of code J1817 is insulin for administration through DME (i.e., insulin pump) per 50 units. 
 
We find that CPT code 96365, 96366, 96521, and J1817 is not supported in the medical record. Specifically, 
the records show that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more 
appropriate set of codes for these services. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 96365, 96366, 96521, and J1817 billed for February 1, 2023.
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 Plan denied your request. The Plan 
says  
 
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 is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45380 provided on February 4, 2023. 
 
You asked the Plan to pay for procedure code 45380. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. The rules say that for purposes of payment under the Medicare Physician 
Fee Schedule (MPFS), the place of service (POS) code is generally used to reflect the actual setting where the 
beneficiary receives the face-to-face service. However, there are two exceptions to this general rule  these are 
for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 45380 have not been met. The file shows that the enrollee was registered as an 
inpatient of a hospital on the date of service procedure code 45380 was provided. The outpatient POS code on 
the claim is inappropriate in this case. Therefore, we decided that the Plan does not have to pay for procedure 
code 45380 provided on February 4, 2023.