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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the level of care needed. 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 record indicates that the enrollee remains critically ill and still requires acute 
critical care services. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that they are not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232-25 billed for date of service June 8, 
2023.  
 
You asked the Plan to pay for procedure code 99232-25. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 99232-25 is bundled into payment for 
code 99233. 
 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 
99232-25 is a column two code to column one code 99233 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 99232-25 billed for date of service June 8, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Koya Dayspring active non-pneumatic compression 
identified with codes K1024 and K1033. 
 
You asked the Plan to pre-approve Koya Dayspring active non-pneumatic compression. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
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 pre-approve Koya Dayspring active non-pneumatic 
compression. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the medical necessity 
of the devices in question. The documentation does not describe that the enrollee has significant lymphedema 
recalcitrant to current treatment. There is no documentation in the medical record that the provider was 
recommending a nonpneumatic compression garment. There is no evidence that the enrollee has undergone or 
was referred for lymphedema treatments. It appears that the advocate for the specific garment under review is 
an employee of the manufacturer. Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Koya Dayspring active non-pneumatic compression have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Koya Dayspring active non-pneumatic 
compression identified with codes K1024 and K1033.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) skilled nursing home health visits. You asked the Plan to pre-approve home health services. You say that you are bed-bound and cannot leave the 
house; these services are medically necessary as you are completely dependent on care. The Plan denied your 
request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
documentation provided does not specify any acute clinical status, medication or plan of care changes or any 
complex wounds to necessitate 10 additional home health skilled nursing visits. Additionally, documented 
patient/family concerns are regarding functional impairments (getting up going to bathroom, feeding, etc.) as 
opposed to skilled nursing needs. Therefore, the additional visits requested are not medically necessary in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten (10) skilled nursing home health visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection (20611) at an outpatient 
hospital provided on August 21, 2023. 
 
You asked the Plan to waive the copayment for the injection (20611) at an outpatient hospital. You say that the 
cost share is wrong. 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 $350 
copayment for outpatient hospital services. 
 
You have been asked to pay a $350 copayment for the injection (20611) at an outpatient hospital. This 
item/service falls within the outpatient hospital 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. However, the allowed amount is less than the copay, so you 
only owe $300.71. Therefore, we decided that the Plan does not have to waive the copayment for the injection 
(20611) at an outpatient hospital provided on August 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 an IRF admission is medically necessary before you 
will be able to return home. The Plan denied your request. The Plan says your needs can be met at an alternate 
level of care, at a skilled nursing facility (SNF).  
 
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 your medical complexity does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. You do not require an intensive rehabilitation therapy, and it is 
unclear if you would tolerate the required therapy. There is not a reasonable expectation that you will be able to 
benefit from the intensive rehabilitation 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 the GTC Hematology Profile billed with code 81455 for date 
of service May 24, 2023. You asked the Plan to pay for the GTC Hematology Profile. You say that this test was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this test was not billed 
correctly. 
 
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 81455 is not supported in the medical record. Specifically, MolDX guidelines state that 
the test at issue should be billed with CPT code 81479 and unique identifier ZB9GO. Although the appropriate 
unique identifier was used in this case, the appropriate corresponding CPT code was not reported. Based on this 
information, we decided that Medicare rules for coverage of the GTC Hematology Profile have not been met. 
Therefore, we decided that the Plan does not have to pay for the GTC Hematology Profile billed with code 
81455 for date of service May 24, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 80307 and G0483. We 
decided that the Plan does not have to pay for the services described by procedure code P9604.  
 
You asked the Plan to pay for the lab testing billed for date of service October 25, 2022. The Plan says that the 
billed code is not supported. 
 
We decided that the Plan has to pay for the services described by procedure codes 80307 and G0483.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 80307 and G0483.  
 
We also decided that the Plan does not have to pay for the services described by procedure code P9604. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The CPT Code Manual definition of code P9604 is travel allowance one way in connection with medically 
necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip 
charge.  
 
We looked at the file, and Medicare rules. We find that code P9604 is not supported in the medical records. 
There are insufficient records to show that the criteria for a specimen collection fee were met. A travel 
allowance is only paid when the specimen collection fee is paid. Based on this information, we decided that 
Medicare rules for coverage of the services described by procedure code(s) P9604 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code P9604. 
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve the medication. You say that you have tried the pill form of statins. You say 
that the side effects were unbearable. You also say that this is medically necessary. The Plan denied your 
request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.
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 requires this level of care. 
The Plan denied your request. The Plan says LTACH criteria are not met in this case. 
 
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 is a female who was admitted to the acute care hospital with colon mass 
with bowel obstruction requiring total parenteral nutrition (TPN), subtotal colectomy surgery, ileostomy with 
fascial closure, drain, wound care, wound vac, antibiotics, and physical therapy.  
 The enrollee appears to be improving with current treatment and should only require short-term additional 
acute care services that can safely be provided at the current facility until appropriate for transfer to a lower 
level of care. The enrollee does not require services at the LTACH that are not already available at the current 
facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99291 billed for date of service April 5, 2023. 
 
You asked the Plan to pay for code 99291. You say that the enrollee was seen twice on this date of service- 
once for an evaluation and management (E/M) service, and once for the critical care service. Medicare allows 
payment for both services on the same day. The Plan denied your request. The Plan says the code at issue is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes on a given calendar date of service. 
 
 We find that CPT code 99291 is not supported in the medical record for two reasons. First, the code definition 
is time-based, and the records submitted for review do not document the total time spent providing the services 
described by this code.  
 
Second, you argue in your appeal request that the enrollee was seen twice on this date of service- once for a 
E/M service, and once for the critical care service in dispute in this appeal. You stated that because the critical 
care service at issue in this appeal occurred after the E/M service, it should be payable.  However, you have 
failed to provide records supporting two distinct services.  You only provided one record, so there is no 
evidence that two separate encounters occurred.  The Plan attempted to get additional records from you on 
multiple occasions, but no additional records were provided. Based on this information, we decided that 
Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99291 billed for date of service April 5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate (J8610). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been taking methotrexate with 
therapeutic control since 2017. You also say that this is continuation therapy.  The Plan denied your request. 
The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Additionally, the provider confirmed that this drug is not being requested for cancer 
treatment. Therefore, we decided that the Plan does not have to pre-approve methotrexate (J8610).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on November 3, 2022, to 
November 5, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
coding of I21.4 (Non-st elevation (nstemi) myocardial infarction) was correct, and the claim should be paid at 
the original DRG billed. The Plan denied your request. The Plan says that although the diagnosis I21.4 (Non-st 
elevation (nstemi) myocardial infarction) is documented, reasonable clinical evidence within the health record 
must be present to clinically validate the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with I21.4 (Non-st elevation (nstemi) myocardial 
infarction). 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the billed diagnosis of I21.4 (Non-st elevation (nstemi) 
myocardial infarction) is supported by the medical record. Our physician reviewer found the patient had an 
elevated troponin without any electrocardiogram (EKG) changes, consistent with the diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on November 3, 2022, to November 5, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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 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 you do not meet the Medicare 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. 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. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that you 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.