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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria. 
 
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 was admitted for cirrhosis, ascites and transaminitis. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. 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 this 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 procedure codes 87798 and 87801 billed for date of service 
January 28, 2023.  
 
You asked the Plan to pay for procedure codes 87798 and 87801. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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. 
 We find that CPT codes 87798 and 87801 are not supported in the medical record. Specifically, no medical 
records were provided to support the services rendered. Documentation must be submitted to support claims 
payment. Without this required documentation, the services rendered cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 87798 and 87801 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87798 and 87801 billed for 
date of service January 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) (78815). 
 
You asked the Plan to pre-approve a Positron emission tomography. The Plan denied your request. The Plan 
says your records do not show the services is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 a Positron emission tomography. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you do not have an 
indication for which a PET Scan can be covered at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Positron emission tomography have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) (78815).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29876 billed for date of service July 12, 
2022. 
 You asked the Plan to pay for procedure code 29876. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 29876 is bundled into 
payment for code 29880. 
 
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 29876 
is a column II code to column I code 29880. 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 29876 billed for date of service July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 1, 2023, billed 
with procedure code 15853. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the place of service is inappropriate for the 
procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that codes with PC/TC status indicator 5 cannot be 
paid when provided to hospital inpatients or patients in a hospital outpatient department. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the practitioner services provided have not been met. Procedure code 15853 has a status indicator 5 
and is not payable in the hospital setting. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on February 1, 2023, billed with procedure code 15853.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hereditary breast cancer-related disorders genomic 
sequence analysis panel (81432) and hereditary breast cancer-related disorder; duplication/deletion analysis 
panel (81433).  
 You asked the Plan to pre-approve hereditary breast cancer-related disorders genomic sequence analysis panel 
and hereditary breast cancer-related disorder; duplication/deletion analysis panel. You say that you have a 
family history of cancer. The Plan denied your request. The Plan says you have stage II prostate cancer and 
therefore do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS panels may be covered when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hereditary breast cancer-related disorders genomic sequence analysis panel and hereditary breast 
cancer-related disorder; duplication/deletion analysis panel have not been met. Specifically, the documentation 
does not support that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV 
cancer. Therefore, we decided that the Plan does not have to pre-approve hereditary breast cancer-related 
disorders genomic sequence analysis panel (81432) and hereditary breast cancer-related disorder; 
duplication/deletion analysis panel (81433).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide acupuncture for spinal stenosis. 
 
You asked the Plan to provide acupuncture. You say that acupuncture for your spinal stenosis used to be 
covered. The Plan denied your request. The Plan says that acupuncture is only covered for chronic low back 
pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the requested acupuncture is not for chronic low back 
pain. Therefore, we decided that the Plan does not have to provide acupuncture for spinal stenosis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuroplasty and a tendon lengthening procedure provided 
on August 31, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a neuroplasty and a tendon lengthening procedure. You say that this was 
medically necessary. 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 a neuroplasty and a tendon lengthening procedure 
provided on August 31, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. The Plan denied your request. The Plan says that the requested 
drug is not covered outside of a Medicare approved clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Leqembi have not been met. Specifically, there is no indication that the enrollee is enrolled in a 
clinical trial or an approved study for Leqembi. Therefore, we decided that the Plan does not have to pre-
approve Leqembi.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee requires 10 additional 
physical therapy visits. The Plan denied your request. The Plan says the requested services are not reasonable 
and necessary, and the health plan has no contractual obligation to cover these services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
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 medical records support the need for IRF 
admission.  The Plan denied your request. The Plan says based on the available information, admission to IRF 
is not reasonable and necessary, as the enrollee's condition does not meet the Medicare rules. 
 
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 is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. No acute rehabilitation nursing needs are 
identified. The complexity of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) 
do not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative 
care. The enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as 
in a skilled nursing 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 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria. 
 
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 hospitalized for pneumonia, heart failure and ankle fracture. Your ankle 
was repaired, and you were medically stabilized. You are functioning at a high level following a prolonged 
hospital stay and with non-weight bearing status on your ankle. You are functioning near to home care level. 
You do not require complex or intensive rehabilitation. Admission to an IRF is not medically 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical scraping provided on February 23, 2023. 
 
You asked the Plan to pay for a surgical scraping. You say that this was medically necessary and 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 a surgical scraping 
provided on February 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 17, 2023, to 
April 15, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. 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 March 17, 2023, to April 
15, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional time for neuropsychological testing.  
 You asked the Plan to pre-approve the additional neuropsychological testing time. You say that it is felt that all 
requested units should be approved.  The Plan denied your request. The Plan says 8 hours of this testing have 
been approved. There is no specific need documented for additional time.  
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing may be covered for the 
indications listed in the Medicare rules section. Supporting documentation in the medical record must be 
present to justify greater than 8 hours per patient per evaluation.  
 
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 additional neuropsychological 
testing time. Our reviewer says that the amount of neuropsychological testing approved by the Plan is 
appropriate, and additional units are not medically necessary.  Our physician reviewer found this enrollee does 
not meet the criteria the extra neuropsychological testing. It is unclear how the extra testing would be used to 
benefit this enrollee, and therefore is not medically necessary or reasonable. It is unclear what questions are to 
be answered by neuropsychological testing. 
 
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 additional neuropsychological testing time have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the additional time for neuropsychological testing.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the stress test, the technetium Tc-99m 
sestamibi injection, the regadenoson injection, and the nuclear medicine study of the heart provided by an in-
network provider on December 19, 2022.  
 
You asked the Plan to waive the cost sharing for the stress test, the injections, and the nuclear medicine study. 
You say that you think that the cost sharing is too high. 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 20% 
coinsurance for all other Medicare-covered Part B drugs, a 20% coinsurance for each Medicare-covered 
medical supply, a $20 copayment for Medicare-covered non-radiological diagnostic services, which includes 
treadmill stress tests, and a $75 copayment for Medicare-covered radiological diagnostic services, which 
includes nuclear studies, performed in a physicians office or at a free-standing facility (such as a radiology 
center or medical clinic). 
 
You have been asked to pay a $49.08 coinsurance for the regadenoson injection ($245.40 allowed amount x .20 
= $49.08). This item/service falls within the Medicare Part B prescription drugs benefit category. You have 
been asked to pay a $20 copayment for the stress test. You have been asked to pay a $92.40 coinsurance for the 
technetium Tc-99m sestamibi injection ($462 allowed amount x .20 = $92.40). You have also been asked to 
pay a $75 copayment for the nuclear medicine study. 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 cost sharing 
for the stress test, the technetium Tc-99m sestamibi injection, the regadenoson injection, and the nuclear 
medicine study of the heart provided by an in-network provider on December 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-rays provided on January 19, 2023. 
 
You asked the Plan to waive the copayment for the x-rays. You say that the providers did not use the x-ray 
images, and the procedure could have been harmful to your health. 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 $10 
copayment for outpatient diagnostic tests, including x-rays. 
 
You have been asked to pay a $10 copayment for the x-rays. This item/service falls within the outpatient 
diagnostic tests, including x-rays 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 x-rays provided on January 19, 2023.