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

 
We decided that the Plan does not have to pre-approve an acute inpatient mental health admission. 
 
You asked the Plan to pre-approve an inpatient mental health admission. You say that the enrollee is 
experiencing symptoms that they cannot control. You also say that you do not understand why this is being 
denied. The Plan denied your request. The Plan says the requested treatment unit is inconsistent with an 
inpatient treatment setting. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 an inpatient mental health admission. 
Our reviewer says that the requested inpatient mental health admission is not medically necessary. Our 
physician reviewer found based upon review the records provided for the admission of the enrollee does not 
meet criteria for acute inpatient mental health treatment as the enrollee was not shown to be a danger to 
themself or others, no auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant 
with treatment while not showing any aggressive behaviors. Therefore, the reviewer found that the requested 
inpatient mental health admission is not medically reasonable or 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 an inpatient mental health admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an acute inpatient mental health admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and diagnostic laryngoscopy provided on 
August 1, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that you see this doctor every year. You say that 
you were told you could continue to see this doctor when you signed up for this Plan. You also say that this 
should be covered. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 office visit and diagnostic laryngoscopy 
provided on August 1, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code P9603, defined as travel allowance one way in 
connection with medically necessary laboratory specimen collection drawn from home bound or nursing home 
bound patient; prorated miles actually travelled, billed for August 9, 2023.  
 
You asked the Plan to pay for P9603. You say that P9603 should be paid as billed because the claim was 
separated, and a collection service was performed. The Plan denied your request. The Plan says P9603 is 
denied because a specimen collection was not found in the available data. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS pays a travel allowance when the specimen 
collection fee is paid.  
 
We looked at the file and Medicare rules. We have confirmed that code P9603 was billed without any other code on the claim. The case file also does not contain evidence of a specimen collection code being billed in 
conjuction with P9603, a specimen collection service being performed, or a specimen collection fee being paid. 
Since there is no covered specimen collection in this case, P9603 would not be payable. Based on this 
information, we decided that Medicare rules for coverage of P9603 have not been met. Therefore, we decided 
that the Plan does not have to pay for code P9603, defined as travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled, billed for August 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 
27, 2023.  
 You asked the Plan to pay for procedure code 86077. You say that you disagree with the Plan's denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 27, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99406 billed for date of service August 11, 2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says that the code was 
reported with code 99215. 
 
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 looked at the file and the rules. There are no procedure-to-procedure edits for code pair 99406 and 99215. 
A modifier is not required for code 99406 when billed with code 99215. Based on this information, we decided 
that Medicare rules for coverage of the billed service have been met. Therefore, we decided that the Plan has to 
pay for procedure code 99406 billed for date of service August 11, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that this is needed. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for IMRT. 
 
The Plan follows Medicare rules. Medicare rules state that IMRT may be covered under certain conditions. 
 
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 IMRT. Our reviewer says that the 
enrollee does not meet criteria for IMRT. Our physician reviewer found it may be that the target volume is in 
close proximity to critical structures that must be protected, but it is not shown that IMRT is needed to protect 
the structures. The other coverage indications do not apply. Palliative treatment of metastatic disease where the 
prescribed dose does not approach normal tissue tolerances suggests lack of necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service June 8, 2023.  
 
You asked the Plan to pay for procedure code 99221. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99221 is bundled into payment for code 
99222. 
 
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 99221 
is a column two code to column one code 99222 with a modifier indicator of 0. The column two code is therefore not payable. 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 99221 billed for date of service June 8, 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 enrollee is a high risk for falls, injury, and 
readmission to acute care. You say that the enrollee needs cannot be safely met with home health services or a 
skilled nursing facility. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the injection services provided on January 
14, 2023. 
 
You asked the Plan to pay for an office visit and the injection 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 an office visit and the 
injection services provided on January 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the CMS 
established defining criteria for a medically appropriate LTACH admission. The Plan denied your request. The 
Plan says continued stay at an acute hospital until the enrollee is stable enough for discharge to a lower level of 
care. The lower level of care has not been denied. 
 
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 class III obesity, chronic obstructive pulmonary disease on 4 liters of 
supplemental oxygen, type 2 diabetes, stage 3 chronic kidney disease and required mechanical ventilation after congestive heart failure exacerbation secondary to pneumonia. The enrollee's kidney disease progressed to 
requiring dialysis and she also underwent tracheostomy and gastrostomy placement. At this time, the enrollee is 
nearly weaned from pressure support ventilation and is unlikely to require greater than or equal to 25 days of 
hospitalization. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the vision services provided on December 
02, 2022. 
 
You asked the Plan to pay for an office visit and the vision 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 an office visit and the 
vision services provided on December 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 06, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records. 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 laboratory services 
provided on July 06, 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 enrollee needs IRF services to return to being 
independent. The Plan denied your request. The Plan says the enrollee does not meet the requirements for an 
IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. 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 pay for the acupuncture services provided on July 21, 2023. 
 
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 July 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 enrollee needs aggressive rehabilitation to regain 
normal functioning. The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
but skilled therapies as an outpatient or at a skilled nursing facility may be approved upon request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and 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 the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81479 billed for date of service April 19, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the billed code is the most appropriate. The Plan 
denied your request. The Plan says that an appropriate CPT code was not billed. 
 
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 code 81479 is supported. The Plan has not shown that the proprietary test provided was 
assigned a specific CPT code for billing. Based on this information, we decided that Medicare rules for 
coverage of the billed testing have been met. Therefore, we decided that the Plan has to pay for procedure code 
81479 billed for date of service April 19, 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: 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 enrollee needs to be transferred to an 
LTACH as medical condition has stabilized requiring a multi-disciplinary approach for an extended period. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer to an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Given there are offered alternatives, LTACH 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 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.