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 live alone and need additional therapy with your 
arm so you may be able to continue with daily activities. The Plan denied your request. The Plan says you do 
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 your 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that without this intense treatment you will decline and 
not regain mobility. The Plan denied your request. The Plan says your records do not show that you need an 
intensive team for your 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 that 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network wound care procedure 
provided on February 10, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network wound care procedure. You say that this charge 
is excessive. You should not have to pay this much 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 15% 
coinsurance for Medically-necessary medical or surgical services furnished in a certified ambulatory surgical 
center or hospital outpatient department.  The allowed amount of this procedure is $2,542.08, resulting in a coinsurance amount of $381.32 ($2,542.08 x 
15% = $381.32). 
 
You have been asked to pay a $381.32 coinsurance for an in-network wound care procedure. This item/service 
falls within the Medically-necessary medical or surgical services furnished in a certified ambulatory surgical 
center or hospital outpatient department 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 coinsurance 
for an in-network wound care procedure provided on February 10, 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 you need inpatient rehabilitation after suffering 
recurrent urinary tract infections and atrial fibrillation so that you can retain maximum function. The Plan 
denied your request. The Plan says the IRF care is not medically necessary, and your needs can be met at a 
lower level of care, such as a skilled nursing 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 you were admitted for weakness and urinary tract infection. Your medical problems 
are stable, and 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 and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. 
 
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 a rest home visit provided on October 29, 2022. 
 
You asked the Plan to pay for a rest home visit. 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 a rest home visit 
provided on October 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service February 5, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this service was medically necessary. The 
Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service February 5, 2023, billed 
with code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on December 09, 2022, to 
December 16, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that you are requesting reconsideration of 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 acupuncture services 
provided on December 09, 2022, to December 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service September 
24, 2022. 
 
You asked the Plan to pay for procedure code 12001. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 12001 is bundled into 
payment for code 26750. 
 
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 12001 
is a column II code to column I code 26750. 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 code 12001 billed for date of service September 24, 
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 the services are medically necessary for the enrollee 
because they are not mobile, need dialysis and physical therapy. The Plan denied your request. The Plan says 
the enrollee does 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 11, 2022, 
to March 8, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 11, 2022, to 
March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel test 
provided on February 28, 2023. 
 
You asked the Plan to pay for the urine PCR panel test. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not payable. 
 The Plan must follow Medicare rules. Medicare rules say that a bacterial urine culture is a laboratory procedure 
performed on a urine specimen to establish the probable etiology of a presumed urinary tract infection. It is 
common practice to do a urinalysis prior to a urine culture. 
 
We looked at the file and Medicare rules. Review of the file shows that the standard of care for the evaluation 
of urinary incontinence is urinalysis with urine culture and sensitivity. Based on this information, we decided 
that Medicare rules for coverage of the urine PCR panel test have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel test provided on February 28, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88365, and 88381 
billed for date of service May 11, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88365, and 88381. You say that this 
service was medically necessary. The Plan denied your request. The Plan says this code is included in the 
facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
88365, and 88381. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88341, 88342, 88360, 88365, and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88365, and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88365, and 88381 billed for date 
of service May 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance and air mileage services provided on July 
1, 2022. 
 
You asked the Plan to pay for the air ambulance and air mileage services. 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 services billed with the GZ modifier will 
automatically be denied. 
 
 We looked at the file and Medicare rules. Review of the file shows that the air ambulance and air mileage 
services were billed with the GZ modifier. This means these services are non-covered as billed. Based on this 
information, we decided that Medicare rules for coverage of the air ambulance and air mileage services have 
not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance and air mileage 
services provided on July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation services provided on 
December 12, 2022. 
 
You asked the Plan to waive the copayment for hospital observation services. You say that you were only in 
the emergency room when services were rendered. 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 $300 
copayment for Medicare-covered observation services. 
 
You have been asked to pay a $300 copayment for hospital observation services. This item/service falls within 
the Medicare-covered observation 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 hospital observation services provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services 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 an office visit provided 
on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on January 
18, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with 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 $250 
copayment for outpatient surgery. 
 
You have been asked to pay a $250 copayment for an outpatient surgery. This item/service falls within the 
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. However, you are only being asked to pay $203.52 which is less than the required amount. 
Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided 
on January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service February 23, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code A4239 is considered bundled/excluded and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4239 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4239 is not separately payable as billed. Based on this information, we decided that Medicare 
rules for coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A4239 billed for date of service February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing evaluation provided on March 
14, 2023. 
 
You asked the Plan to waive the copayment for the hearing evaluation. You say that you though this was a 
normal hearing exam. 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 $40 
copayment for hearing services. 
 
You have been asked to pay a $40 copayment for the hearing evaluation. This item/service falls within the 
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. The record shows this was a diagnostic hearing exam. Therefore, we decided that the Plan does not 
have to waive the copayment for the hearing evaluation provided on March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye exam, and related services provided on August 
24, 2022. 
 
You asked the Plan to pay for a medical eye exam, and related services. You say that these 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 a medical eye exam, and 
related services provided on August 24, 2022.