Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is extremely pleased with 
the results of the trial. The Plan denied your request. The Plan says the enrollee has two pathologies listed in 
the exclusion criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that sacral nerve stimulation for urinary incontinence 
is only covered under certain medical indications.  
 
We looked at the file and Medicare rules. The records provided show that the enrollee has indications that limit 
coverage, such as diabetic neuropathy and benign prostatic hyperplasia. Based on this information, we decided 
that Medicare rules for have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
sacral nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided on January 4, 2020. 
 
You asked the Plan to pay for critical care. You say that this was coded correctly. The Plan denied your 
request. The Plan says the time spent on this service was not documented. 
 
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. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, this code is for 30-74 
minutes of care, and the time spent on this service is not documented in the records. Without this information, 
this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of critical 
care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) 
provided on January 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Botox injection. 
 
You asked the Plan to pre-approve an Onabotulinumtoxina injection. You say that your dentist recommended 
Botox to help with your bruxism and related headaches. The Plan denied your request. The Plan says Botox 
injections for Bruxism are not covered. 
 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 an Onabotulinumtoxina injection 
(J0585). Our reviewer says that Botox is not currently FDA approved for use in the management of Bruxism. 
Nor is it readily supported for use in the Medicare Accepted Compendia for bruxism. Likewise, Botox is not 
supported for use in Bruxism per the applicable Local Coverage Determination and Local Coverage Article. 
Our physician reviewer found while Botox is FDA approved for use in chronic migraine headaches, the 
medical records provided for review do not support a diagnosis of chronic migraine. Botox has not otherwise 
been shown to be safe and/or effective for use in any other type of headache disorder(s). 
 
In this regard it cannot be said that the requested medication, Botox would be reasonable and necessary for this 
member's condition. 
 
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 Onabotulinumtoxina injection (J0585) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Botox injection.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that it would not cause excessive physical hardship for the patient to receive 
needed care in an outpatient basis or skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for worsening left sided 
weakness. She was diagnosed with stroke and had vascular intervention. The enrollee's medical problems are 
stable. There are no identified problems that need inpatient medical management. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record 
supports a need for physical and occupational therapy but it does not support a need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered for cosmetic reasons. 
 
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 the surgery. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation supports that the panniculectomy is not being done for functional reasons. The 
medical records do not demonstrate an inability to walk normally, chronic pain, ulceration created by the 
abdominal skin fold, or intertrigo dermatitis, nor is there documentation of chronic intertrigo that consistently 
recurs over three months while receiving appropriate medical therapy, or remains refractory to appropriate 
medical therapy over a period of three month 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve panniculectomy for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on May 28, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360 and NEXT-Generation) 
requires use of CPT 81479 (for the entire multi-test panel). 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on March 7, 2020 to 
March 9, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
include a critical care visit of 30-74 minutes was performed. The documentation does not include the time 
spent providing the service. Based on this information, we decided that Medicare rules for coverage of the 
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
critical care services provided on March 7, 2020 to March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness 
and electronic connection for the enrollee. 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that there is not a medical need to control these power options through the 
joystick. 
 
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 these items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. The 
documentation does not reveal that the patient requires other types of proportional input devices or non-
proportional input devices. The patient does not need to operate 3 or more powered seating actuators through 
the drive control, a separate display, other electronic devices, or an attendant control. The patient's strength is 
sufficient to control any powered options through their own individual switches. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of these 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 these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller, expandable controller harness and electronic connection for the 
enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the ultrasound you had on March 20, 2020. 
 
You asked the Plan to adjust the copayment. You say that there should only be a $30 copayment. The Plan 
denied your request. The Plan says you are responsible for the copayment 
 
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 $115 
copayment for each Medicare-covered radiological diagnostic service.  
 
Review of the file shows that you had an ultrasound on March 20, 2020. Per your contract with the Plan, there 
is a $115 copayment for an ultrasound. However, the Medicare allowed amount for the ultrasound was $83.87. 
Since the allowed amount was less than the $115 copayment, you have been asked to pay the lesser amount. 
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 adjust the copayment for the ultrasound you had on March 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc-One knee injections.You asked the Plan to pre-approveSynvisc-One (J7325). You say that the enrollee has knee pain.The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Monvisc and Orthovisc.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Synvisc-One (J7325). Our reviewer says that the injections are not medically necessary. Our physician reviewer found criteria for Synvisc is not met. There is no documentation of first line ortho or monovisc injection therapy.Synvisc is not medically needed. Recent literature shows the injections don't work well for knee degenerative joint disease pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One (J7325) have not been met.Therefore, we decided that the Plan does not have topre-approveSynvisc-One knee injections.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided on April 14, 2020. 
 
You asked the Plan to pay for lab testing. You say that you are appealing with supporting records and proof of 
Medicare coverage. The Plan denied your request. The Plan says that the denial of payment for this testing is 
correct, because this testing must be billed with Current Procedural Terminology (CPT) code 81479. 
 
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. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering provider was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. The Plan cited Local Coverage Article (LCA) A55624 as justification for non-
coverage based on the coding of this test; however, A55624 does not have jurisdiction over this lab and 
therefore is not relevant to this case. Therefore, the Plan has not shown that its decision to deny payment is 
correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory 
testing provided on April 14, 2020.   
 
 
 
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 pay for the medical services provided to the enrollee by an out-of-
network provider on January 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services.  
 
 
 
 
 
 
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an 
out-of-network provider on January 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided May 5, 
2020 to Mary 13, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF 
services. The Plan denied your request. The Plan says the enrollee was not physically in the nursing facility and 
therefore was not receiving skilled care from the facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided May 5, 2020 to Mary 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99601, CPT 99602) provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Codes 99601 and 99602 are assigned a status indicator of ?I? under 
the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 99601, CPT 99602) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 16, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a telehealth visit and 
you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were 
processed correctly, and you are being charged the correct amount. 
 
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 $25 
copayment for services obtained by a Tier 2 primary care physician.  
 
You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's 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 a specialist visit provided on April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes 
(99239) provided March 5, 2020. 
 
You asked the Plan to pay for hospital discharge day management. You say that the documentation does 
support the level billed. If you downcode the charge, the plan will deny again or say the code is invalid. If the 
plan does not pay, you will bill the enrollee. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management of more 
than 30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge 
summary does not support hospital discharge day management of more than 30 minutes was performed. A 
documented duration of time of 31 minutes or more is required to support this code. Based on this information, 
we decided that Medicare rules for coverage of hospital discharge day management have not been met.  
Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 
minutes (99239) provided March 5, 2020.