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

 
We decided that the Plan does not have to pre-approve an in-network exception for the medical services to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve an in-network exception for the pain management visits. You say that you 
would like reconsideration because these services are medically necessary and you would like to remain with 
this provider. The Plan denied your request. The Plan says there are no in-network inadequacies seen for an in-
network benefit exception. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that your share of the cost may be higher for an out-of-network provider. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve an in-network exception for these items/services. Please note, the Plan has pre-
approved a 60-day transition from you to locate an in-network provider. Therefore, we decided that the Plan 
does not have to pre-approve an in-network exception for the medical services to be provided by an out of 
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT) scan of stomach area and pelvis with and without contrast (74178).You asked the Plan to pre-approvethe CT scan. You say that you have been getting CT scans for your kidneys for the last 2 years because you have cysts on one of your kidneys.The Plan denied your request. The Plan says the records received did not indicate the medical necessity for the need of the CT scan.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found benign renal cysts can be safely monitored with periodic ultrasound scans and further evaluation with CT scan undertaken if there are any changes on ultrasound. CT scans may also be performed if the enrollee develops symptoms such as hematuria or flank pain. In this case, a CT Scan does not appear to be medically reasonable and necessary because there are no new symptoms and the prior CT on 1/27/20 was unchanged.We looked at this physician's review, thefile, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) scan of stomach area and pelvis with and without contrast (74178)
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 meets the LTACH 
admission criteria under CMS guidelines. You say that the enrollee is stable and suitable for transfer to an 
LTACH. You say that the enrollee cannot be adequately cared for in his current condition at a skilled nursing 
facility. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been 
met. The Plan says that the enrollee's illness is not complex enough to require further hospital care. The Plan 
says that the continued care needed can be received in another setting. 
 
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 ongoing care needs include surveillance laboratory studies, wound care,  glucose 
monitoring, and therapy services. 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on May 28, 2020. 
 
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 procedure code 70450 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a 
modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan of the head/brain rendered on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve conduction test (95909) and a 
muscle test (95886) performed on June 17, 2020. 
 
You asked the Plan to waive the copayment for a nerve conduction test and a muscle test. You say that you've 
never paid such a price before and that the Plan should provide more coverage. The Plan denied your request. 
The Plan says the correct copayment was applied. 
 
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 Medicare-covered diagnostic procedures and tests, excepting EKG and diagnostic colorectal 
screenings. 
 
You have been asked to pay a $200 copayment for a nerve conduction test and a muscle test. A nerve 
conduction test and a muscle test fall within the "Outpatient diagnostic tests and therapeutic services and 
supplies" benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a nerve conduction test 
(95909) and a muscle test (95886) performed on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic footwear (tennis-type shoe) and sales tax provided 
on April 29, 2020. 
 
You asked the Plan to pay for foot orthotics and sales tax. You say that the enrollee needed these shoes to 
resolve the problem with her leg/foot brace. The Plan denied your request. The Plan says the denial of payment 
for these items is correct, because this provider does not participate with Medicare and is not eligible for 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items and 
services, a provider or supplier must be enrolled in the Medicare program. The rules also say that Medicare 
does not make separate payment for sales tax. 
 
We looked at the file and Medicare rules. This provider is not enrolled in the Medicare program and is not 
eligible for payment. Additionally, the sales tax you requested reimbursement for is not separately payable by 
Medicare. Based on this information, we decided that Medicare rules for coverage of foot orthotics and sales 
tax have not been met. Therefore, we decided that the Plan does not have to pay for orthotic footwear (tennis-
type shoe) and sales tax provided on April 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on February 25, 2020. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance, periodic oral evaluation, and 
bitewings provided on May 13, 2020. 
 
You asked the Plan to pay for the periodontal maintenance, periodic oral evaluation, and bitewings. You say 
that you have seen this provider since 2014, but had to change plans. You also say that this was your first visit 
with this provider under your new plan, and Part C has always paid something for the services rendered. The 
Plan denied your request. The Plan says the treating provider opted out of Medicare. The Plan also says that 
services performed by a privately contracted provider are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodontal maintenance, periodic oral evaluation, and bitewings provided on May 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for secondary closure of surgical wound, extensive or 
complicated (13160/AS) provided March 6, 2020. 
 
You asked the Plan to pay for the wound closure. You say that please reconsider the reimbursement for the 
assistant surgeon. The first number assistant was required for safe positioning of this morbidly obese patient, 
retraction and complex wound closure. The Plan denied your request. The Plan says payment is not allowed for 
an assistant at surgery because it was not required for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
13160. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for the wound closure have not been met. 
Therefore, we decided that the Plan does not have to pay for secondary closure of surgical wound, extensive or 
complicated (13160/AS) provided March 6, 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 needs the level of care provided in an 
IRF. You say that the enrollee is not in her normal mindset and does not have the normal ability of life. You 
say that the enrollee is able to do therapy and get better. The Plan denied your request. The Plan says the 
enrollee's medical conditions are stable and that complex wound care is not needed. The Plan says that the 
enrollee does not need a multidisciplinary team or visits from a physician. The Plan says that the enrollee does 
not need to participate in physical therapy or occupational therapy five times per week, and her care can be 
handled in a less intensive setting. 
 
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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee is generally medically stable and the documentation does not support that she 
has complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical 
medicine and rehabilitation physician three times per week.  While the enrollee is reasonably expected to benefit from continued physical therapy and occupational therapy, the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your care is not complex enough and you can receive the care you need 
in a lower level of care. 
 
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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services 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 ongoing skilled services can be provided in an alternative setting. 
 
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 
documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs 
requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical condition has stabilized, and the documentation does not support that she has complex medical issues 
that require acute rehab nursing care, or monitoring by an inpatient physical medicine and rehab physician 
three times per week. While the enrollee is reasonably expected to benefit from continued physical and 
occupation therapy, the documentation does not support that there is need for an intensive therapy program 
with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to 
rehabilitation care. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the kind of therapy that is only available in 
an IRF. The Plan denied your request. The Plan says the IRF admission does not meet the requirements for 
approval, and 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 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 you do not require the intensity of services provided at an IRF. Our reviewer found 
that specifically, you do not show that you require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Our physician reviewer also found that your care needs can be met at a lower 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not need 
skilled services. 
 
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 pre-approve SNF services. Our physician reviewer 
found that from a nursing perspective, you received oral medications, you had stable vital signs, and your lungs 
were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a 
standby assist to supervision level with functional mobility. You require varying assist with activities of daily 
living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray (71046) provided on  
March 18, 2020. 
 
You asked the Plan to waive 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 was 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 $35 
copayment for in-network Medicare-covered x-rays.  
 
You have been asked to pay a $33.78 copayment for the in-network Medicare-covered x-ray provided. This is 
the Plan allowed amount, which is less than the applicable copayment. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. If you are being billed for an office visit charge 
by another provider, you should ask that provider to submit a claim to the Plan for payment. 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 chest x-ray (71046) provided on March 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PET (78815) provided on April 13, 2020. 
 
You asked the Plan to pay for the PET. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the diagnosis code billed is not listed as an acceptable 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 78815-26 PS is not supported in the record. Specifically, CMS provides a list of 
appropriate diagnosis codes for billing with PET procedures performed to inform the subsequent treatment 
strategy of cancerous tumors. C50.911 is not listed as an appropriate diagnosis code. Based on this information, 
we decided that Medicare rules for coverage of the PET have not been met. Therefore, we decided that the Plan 
does not have to pay for the PET (78815) provided on April 13, 2020.