Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The Plan denied your request. The Plan says an 
IRF admission is not medically necessary.  
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will receive the appropriate care from an 
IRF admission. You also say that it will optimize the enrollee's level of functioning so she can return home.  
The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services requested 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take-home supply of 
methadone provided on April 24, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take-home supply of methadone. You say 
that a referral, authorization, or notification is not required. 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 medication assisted 
treatment, and a take-home supply of methadone provided on April 24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99214 and 93925 billed for date of service 
September 9, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes cannot be verified. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. We find that code 99214 is not supported in the medical records. The records show that the enrollee presented 
to the office visit for vascular testing. The records do not show that a moderate level of decision making was 
provided. The records do not indicate the amount of time spent with the enrollee on the date of service at issue. 
 
The CPT Code Manual definition of code 93925 is duplex scan of lower extremity arteries or arterial bypass 
grafts; complete bilateral study. We asked our physician to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the billed services. Our 
reviewer found that according to the submitted records the enrollee had bilateral ankle-brachial indices. For 
code 93925 to be reimbursable, the common femoral, superficial femoral, popliteal and dorsalis pedis arteries 
must be each addressed, and such documentation is not present in this case. Therefore, billed code 93925 is not 
supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 99214 and 93925 billed for date of service September 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Reblozyl is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that 
Reblozyl is not medically necessary. Our physician reviewer found that the requested use of Reblozyl is not 
FDA-approved for the enrollee's diagnosis. Reblozyl is also not supported by one of the major drug compendia 
or by clinical research.  
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for esophageal manometry provided on March 
22, 2023. 
 
You asked the Plan to waive the copayment for esophageal manometry. You say that you say that you were 
told you would have no additional cost share since they were supposed to be completed as one charge. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $75 copayment for esophageal manometry. 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 esophageal manometry provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an outpatient surgery provided on May 22, 
2023 
 
You asked the Plan to waive the cost share for an outpatient surgery. You say that you disagree with the cost 
share. 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. Your 
contract with the Plan says that there is a $525 deductible and a 10% coinsurance which applies to outpatient 
surgery.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient surgery benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $525 
deductible and a 10% coinsurance which applies to outpatient surgery. The total allowed amount you are being 
asked to pay is $405.42. You are being asked to pay $386.38 towards your $525 deductible and $1.90 for the 
remaining balance (19.04 x 10% = $1.90). The total amount you are being asked to pay is $388.28 ($236.38 + 
$1.90 =$388.28). This cost sharing is a contractual obligation that had not been met at the time an outpatient surgery was received on May 22, 2023. Therefore, we decided that the Plan does not have to waive the cost 
share for an outpatient surgery provided on May 22, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the amalgam (D2150) for tooth #3 and #15 provided on 
May 26, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the Plan should pay more and they only 
paid a very small amount. The Plan denied your request. The Plan says you are responsible for the difference in 
allowed amount and the proper cost share was applied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The original allowed amount for the resin-based composite (D2392) for tooth #3 was $193. The total allowed 
amount for the approved the amalgam (D2150) for tooth #3 was $142. The difference in the allowed amount 
was $51 ($193 billed - $142 allowed). The coinsurance charged was $71 ($142 allowed x 50% coinsurance). 
The total liability was $122 ($51 difference + $71 coinsurance). The original allowed amount for the resin-based 
composite (D2392) for tooth #15 was $193. The total allowed amount for the approved the amalgam (D2150) 
for tooth #15 was $142. The difference in the allowed amount was $51 ($193 billed - $142 allowed). The 
coinsurance charged was $71 ($142 allowed x 50% coinsurance). The total liability was $122 ($51 difference + 
$71 coinsurance). 
 
You have been asked to pay the difference between the allowed amount of the less expensive alternate 
procedure along with the coinsurance. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for the amalgam (D2150) 
for tooth #3 and #15 provided on May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 20, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that medical records were provided. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation (unattended) (G0283) vasopneumatic 
device (97016) vitamin B12 cyanocobalamin injection (J3420) thiamine injection (J3411) pyridoxine injection 
(J3415) levocarnitine injection (J1955) provided May 18, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that please review the Medical Record and 
process the claim after review.  The Plan denied your request. The Plan says the records do not support the 
service billed. 
 
 
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 pay for the pain treatment. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy. Therefore, the request is deemed not medically 
reasonable and necessary. 
 
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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for electrical stimulation (unattended) (G0283) vasopneumatic device (97016) vitamin 
B12 cyanocobalamin injection (J3420) thiamine injection (J3411) pyridoxine injection (J3415) levocarnitine 
injection (J1955) provided May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 10, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you want to appeal cost sharing on 
claim. 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 Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 office visit provided on May 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95800 provided on March 20, 2023 to March 
21, 2023. 
 
You asked the Plan to pay for procedure code 95800. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed code. 
 
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 95800 is sleep study, unattended, simultaneous recording; 
heart rate, oxygen saturation, respiratory analysis, and sleep time,  . 
 
We find that CPT code 95800 is not supported in the medical record. Specifically, the record shows this was a 
home sleep test. There is a more appropriate code to describe this service (G0400). Based on this information, 
we decided that Medicare rules for coverage of procedure code 95800 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 95800 provided on March 20, 2023 to March 21, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on January 10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the services were ordered by the enrollee's 
treating physician. The Plan denied your request. The Plan says that the services were not authorized. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
Plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on January 10, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service January 10, 
2023.  
 
You asked the Plan to pay for procedure code 88360. You say that the report shows the services were provided 
to treat the enrollee. 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 88360 is 6. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation provided does not include rationale as to why the excess units 
were needed to treat the enrollee in this case. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88360 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 88360 billed for date of service January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management provided on April 30, 2023, by an 
OON provider.   
 
You asked the Plan to pay for the care management. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the care management provided on April 30, 2023, 
by an OON provider.
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 services are medically necessary. The 
Plan denied your request. The Plan says the enrollee can remain in the current acute care location until such 
time no further acute level care is needed. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at 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.