Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on May 6, 
2020. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you had this breast 
ultrasound at the same time as your annual mammogram so it should not be subject to a copayment. The Plan 
denied your request. The Plan says you were charged this copayment 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 $110 
copayment for radiological diagnostic services except for x-rays.  
 
You have been asked to pay a $110 copayment for the breast ultrasound. The breast ultrasound falls within the 
radiological diagnostic services benefit category. This ultrasound is not the same thing as a mammogram that 
carries a $0 copayment. 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 breast ultrasound you had on 
May 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71046, 71275) provided May 27, 2020. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim included an invalid place of service for the CPT codes 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 71046, 71275 is not supported in the medical record. Specifically, the CPT codes at 
issue are not separately payable in a high-level place of treatment. Based on this information, we decided that 
Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan 
does not have to pay for radiology services (71046, 71275) provided May 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 13, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on December 13, 2019.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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. Our physician reviewer found based on the documentation provided, 
the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not 
shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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 adjust the copayment for the needle aspiration biopsy (10005) 
provided on January 20, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $295 
copayment for surgery services provided at an outpatient hospital.  
 
You have been asked to pay a $295 copayment for the surgery services provided at an outpatient hospital. 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 needle aspiration biopsy (10005) provided on  
January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the steroid injections in your shoulder and 
related services you had at an outpatient hospital facility on May 20, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital services. You say that you had no idea 
that you would have this copayment-- you thought you only had to pay a $35 copayment for this service. The 
Plan denied your request. The Plan says you were charged this copayment 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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $200 copayment for the shoulder steroid injections and related services you had 
at an outpatient hospital facility. These types of injections are considered surgical services. 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 steroid injections in your shoulder and related services you had at 
an outpatient hospital facility on May 20, 2020.
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 not ambulatory for 10 feet. You say 
that the enrollee's past medical history should be taken into consideration. You say that the enrollee is retaining 
fluid on dialysis. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not 
been met. 
 
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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital stay with an interdisciplinary approach to rehabilitation care. The enrollee requires 
physical therapy and occupational therapy services, but does not require an intensive inpatient rehabilitation 
therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the 
intensive rehabilitation program provided in an inpatient rehabilitation facility. Care at the skilled nursing 
facility appears to be more appropriate 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 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 interpretation and report of an electrocardiogram (93010) 
provided on April 14, 2020. 
 
You asked the Plan to pay for the interpretation and report of an electrocardiogram. You say that this is a 
payable code. The Plan denied your request. The Plan says this code 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 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We find that CPT code 93010 is not supported in the medical record. Specifically, the submitted medical 
records do not included documentation of an ECG interpretation and report. Based on this information, we 
decided that Medicare rules for coverage of the interpretation and report of an electrocardiogram have not been 
met. Therefore, we decided that the Plan does not have to pay for the interpretation and report of an 
electrocardiogram (93010) provided on April 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested diabetic footwear and inserts. 
 
You asked the Plan to pre-approve the diabetic footwear and inserts. You say that the in-network provider is 
too far from your home and you cannot sit in a car longer than 15 minutes due to hemorrhoids. The Plan denied 
your request. The Plan says that 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve the requested 
diabetic footwear and inserts.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 97530-GP59 provided on March 6, 2020. 
 
You asked the Plan to pay for CPT code 97530-GP59. You say that the medical records support the billing of 
CPT code 97530 GP 59. The Plan denied your request. The Plan says the medical records do not support the 
billing of CPT code 97530 GP 59. 
 
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 97530-GP59 is Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
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 CPT code 97530-GP59. Our reviewer says 
that the medical records do not support the billing of CPT code 97530 GP 59. Our physician reviewer found 
Current Procedural Terminology (CPT) code 97530 GP 59 - Therapeutic activities, direct (one-on-one) patient 
contact (use of dynamic activities to improve functional performance), each 15 minutes was billed to the health 
plan for services provided to the enrollee on March 6, 2020 and does not meet criteria for billing or 
reimbursement consideration. The medical records provided indicate that procedure 97140-Manual therapy 
techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, 
each 15 minutes was performed on the same date of service as 97530.  CPT 97530 is bundled in service 97140. 
However, a modifier is allowed to unbundle the services, providing the medical records include documentation 
to validate the use of the modifier.  However, the medical records provided do not include documentation of 
the specific activities or modalities associated with 97530 GP 59 to corroborate that it is a distinct or separate 
service, therefore, this service cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT code 97530-GP59 have not been met. Therefore, we decided that the Plan 
does not have to pay for CPT code 97530-GP59 provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 15, 2019. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
physician's services. 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 physician's services provided on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 22, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 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 a domiciliary, rest home visit provided on January 22, 2020.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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. Our physician reviewer found the complexity of the enrollee's 
nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The documentation doesn't support that she would meet 
criteria for admission to an acute inpatient rehabilitation facility.  There is no indication that the enrollee would 
require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain his/her functional status. Medicare coverage 
criteria are not met. 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: 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says IRF stay is not supported by the records received. The Plan says 
that, based on the enrollee's current needs, they suggest care in a skilled nursing facility or at home with home 
health services. 
 
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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee requires or that his endurance level can tolerate an 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for L1851, L2397-RT, and L3960 billed for date of service June 
4, 2020. 
 
You asked the Plan to pay for HCPCS codes L1851, L2397-RT, and L3960. You say that the medical records 
provided support the need for the items in dispute. The Plan denied your request. The Plan says there were no 
claims submitted for evaluation and management services. The Plan says that the records provided are not 
sufficient evidence of the criteria for coverage having been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for HCPCS codes L1851, L2397-RT, and 
L3960. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee's chief complaints were right knee pain and right shoulder 
pain, documented in 2 separate notes on the same date of service. The enrollee was evaluated for back pain and 
left knee pain on the same date, with the documentation in 2 other notes. There is no documentation of recent 
injury to, or recent surgical procedure on the enrollee's knee, and there is insufficient credible objective 
documentation of joint laxity. The documentation does not support that the shoulder/arm orthosis was 
medically reasonable and necessary for the enrollee in this case, as there is no documentation of a credible 
physical examination of the shoulder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HCPCS codes L1851, L2397-RT, and L3960 have not been met. Therefore, we 
decided that the Plan does not have to pay for L1851, L2397-RT, and L3960 billed for date of service June 4, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a commode. 
 
You asked the Plan to pre-approve a commode. You say that a commode is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 a commode. Our reviewer says that 
Medicare coverage criteria are not met. Our physician reviewer found the documentation does not support that 
the criteria per Local Coverage Determination (LCD):  Commodes (L33736) has been met. The documentation 
does not show that you are physically incapable of utilizing regular toilet facilities. There is no evidence that 
you are confined to a single room, confined to one level of the home environment and there is no toilet on that 
level, or confined to the home and there are no toilet facilities in the home. Medicare criteria are not met.  
 
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 commode have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a commode.