Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. You say that you would like to continue with therapy 
and get stronger before going home. The Plan denied your request. The Plan says the intensity of service will 
not lead to further improvement due to physical limitations. 
 
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. 
 
Continued services beyond September 18, 2020, were requested. 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 continued services. Our physician reviewer found that the enrollee is walking with 
minimum to moderate assistance with a wheeled walker and is contact guard assist for transfers and he requires 
assistance with activities of daily living due to limited shoulder range of motion. He is medically stable. there is 
no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary 
and reasonable treatment. this patient does not require skilled therapy services, i.e., the specialized skill, 
knowledge and judgment of a qualified therapist is not required to safely and effectively provide medically 
necessary and reasonable treatment. Daily skilled services are not required. Therefore, the enrollee does not 
require skilled services on 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lumbar Vertiflex Interspinous and/or interlaminar 
device (22869). 
 
You asked the Plan to pre-approve a Lumbar Vertiflex Interspinous and/or interlaminar device. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria has not 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 pre-approve a Lumbar Vertiflex Interspinous and/or 
interlaminar device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research 
is needed to show safety and efficacy. There is no instability documented. 
 
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 Lumbar Vertiflex Interspinous and/or interlaminar device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Lumbar Vertiflex Interspinous and/or 
interlaminar device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve SI joint injection. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because the enrollee had an SI joint 
injection on August 7, 2020 so this request exceeds the frequency limit. 
 
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 SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found too frequent injections of intra-articular steroids can lead to side-effects and local 
joint changes. The frequency limit of once every 2 months is evidence based, and this request exceeds this 
frequency limit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99152) provided on January 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older". 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT code 99152 is not supported by the records provided. Our coding reviewer found that the medical 
records submitted do not include documentation of an independent trained observer to assist in the monitoring 
of the patient's level of consciousness and physiological status being present on January 30, 2020. 
 
We looked at this coders review, the file, and Medicare rules. 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 99152) provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for a cataract removal with insertion of intraocular lens prosthesis. We
decided that the Plan does not have to pay for an astigmatism correcting function of intraocular lens.
You asked the Plan to pay for a cataract removal with insertion of intraocular lens prosthesis. You say that
while the lens is not covered the surgery should be paid. The Plan says that this is not covered.
We decided that the Plan has to pay for a cataract removal with insertion of intraocular lens prosthesis.
The Plan follows Medicare rules. Medicare 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 rules also say that Medicare will pay the same amount for cataract extraction with A-C IOL
insertion that it pays for cataract extraction with conventional IOL insertion.
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 has stated that the cataract surgery at issue is not covered by Medicare.
However, cataract surgery is covered by Medicare even when a non-covered IOL is inserted. The Plan has not
submitted any rational as to why this surgery is not covered. Therefore, we decided that the Plan has to pay for
a cataract removal with insertion of intraocular lens prosthesis.
We also decided that the Plan does not have to pay for an astigmatism correcting function of intraocular
lens.
The Plan follows Medicare rules. Medicare rules say that Astigmatism-Correcting Intraocular Lenses are not
covered.
The lens at issue is not covered under Medicare rules. Therefore, we decided that the Plan does not have to pay
for an astigmatism correcting function of intraocular lens.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT Scan of the neck (70491) provided on March 2, 2020 through March 20, 2020.

You asked the Plan to pay for the CT Scan. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 70491 should not be reported with 78815, unless 70491 is performed for other than attenuation correction and anatomical localization

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 asked our coder 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 CT Scan. Our reviewer says that CPT code 70491 does not meet criteria for billing or reimbursement consideration. Our reviewer found Per the AMA CPT manual it is inappropriate report CPT 70491 with CPT 78815 unless CPT 70491 is performed for other than attenuation correction and anatomical localization.

We looked at this coder's review, the file, 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 pay for the CT Scan of the neck (70491) provided on March 2, 2020 through March 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the therapeutic radiology complex simulation-aided field setting 
provided on March 6, 2020 billed with code 77290. 
 
You asked the Plan to pay for the services described by code 77290. You say that this is a separately payable 
service and was medically necessary to the provision of this enrollee's radiation treatment. The Plan denied 
your request. The Plan says that payment for the services identified by CPT codes 77014, 77280, 77285, 
77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 
(IMRT planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or 
as part of the development of the IMRT plan. 
 
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. The Plan has not provided a valid citation on which to base its denial in this 
case. The Plan cites to language from Chapter 4 of the Claims Processing Manual, Section 200.3.1. Section 200 
of this Chapter contains instructions and rules regarding "Special Services for OPPS Billing". This means that 
the instructions therein pertain to outpatient facility claims from a hospital. The rule stating that payment for 
77290 being included in payment for 77301 relates to payment to the hospital facility for these services. The 
claims at issue are for professional services of the physician and are not paid through the Outpatient 
Prospective Payment System (OPPS). The Plan provide no rule to support that separate payment cannot be 
made to a physician for this code. Without a valid denial rationale, we find that the denial of payment is not 
substantiated. Therefore, we decided that the Plan has to pay for the therapeutic radiology complex simulation-
aided field setting provided on March 6, 2020 billed with code 77290.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a colonoscopy with a biopsy (45380) 
provided on March 9, 2020. 
 
You asked the Plan to waive the cost-sharing for a colonoscopy with a biopsy. You say that this should not be 
considered diagnostic since the polyp was benign. The Plan denied your request. The Plan says this was 
diagnostic because a biopsy was taken. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible that applies to outpatient surgery, and when a 
screening colonoscopy or sigmoidoscopy becomes a diagnostic procedure(e.g., results in a biopsy or removal 
of a lesion or growth),then outpatient surgery cost-sharing. 
 
The item or service you asked the Plan to waive the cost-sharing for is a colonoscopy with a biopsy, meaning it 
was correctly processed as outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $750 deductible that applies to this service. This cost sharing is a contractual 
obligation that had not been met at the time a colonoscopy with a biopsy was received on March 9, 2020. 
Therefore, we decided that the Plan does not have to waive the cost-sharing for a colonoscopy with a biopsy 
(45380) provided on March 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service you began to 
experience extreme muscle spasms in your shoulder and upper arms. You say that you called 911 and you were 
ready to go to the hospital for relief. You stated that when the responders arrived, they did not feel it was in 
your best interest to go to the hospital because of the current Covid-19 virus activity. You say that you took 
some medication and you were advised to call back if the pain did not get better. You stated that you did not 
believe you would be charged for the services because the Plan is supposed to cover ambulance services. You 
asked the Plan to reconsider providing coverage because you say that you would have gone to the hospital if 
the EMT responders had not been opposed due to the possibility of exposure to Covid-19. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 26, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient services provided on April 
15, 2020 at an outpatient facility. 
 
You asked the Plan to waive the copayment for the outpatient services. You say that you had the same 
procedure at the same hospital on a different date of service and were assessed a lesser cost-share. The Plan 
denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received outpatient services provided on April 15, 2020 at an outpatient 
facility. You are asked to pay a $370 copayment for the services. Your EOC states that enrollees must pay a 
$370 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges. 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 outpatient services provided on April 15, 2020 at an outpatient 
facility.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
You asked the Plan to waive the copayments for the CT scan and physical and occupational therapy services.. 
You say that the copayments were applied incorrectly.  The Plan says that the correct cost-sharing was applied. 
 
We decided that the Plan does not have to waive the copayment for the CT scan. 
 
Per the evidence of coverage, there is a $250 copayment for Advanced Imaging when performed at an in-
network facility. In this case, the Medicare allowable amount of $103.67 was less than the $250 noted in the 
plan contract, and this amount was correctly applied as the copayment instead. 
 
We also decided that the Plan has to reduce the copayments for the Physical and Occupational therapy 
services. 
 
The enrollee was charged a $63.81 and $88.27 copayment for the Physical and Occupational therapy. Per the 
Evidence of Coverage, the copayment for in-network Physical and Occupational therapy performed in an 
outpatient hospital setting is $35. The record indicates that the services were arranged by in-network providers. 
Based on this information, the in-network cost-sharing amount of $35 should be applied. 
 
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 pay for the acute inpatient hospital care provided from February 14, 
2019 through February 15, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record  did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from February 14, 2019 through 
February 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 23, 
2019. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not be liable for 
the ambulance copay due to being informed that the ambulance services were covered by the Plan. The Plan 
denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 
 
Review of the file show that you received ambulance services on May 23, 2019. You are asked to pay a $250 
copayment for the ambulance services. Your EOC states that enrollees must pay a $250 copayment for ground 
travel ambulance 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 ambulance services 
provided on May 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on March 20, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 20, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on March 
20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for the office visits and the electrical 
stimulation provided from May 13, 2020 through May 22, 2020. 
 
You asked the Plan to waive the cost-share for the office visits and the electrical stimulation. You say that you 
should not be charged more than a $5 copayment. The Plan denied your request. The Plan says the claims were 
processed accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
The copay of $5 is a contractual obligation. The denied services are not a benefit based on the EOC. 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 cost-share for the office visits and the electrical stimulation provided from 
May 13, 2020 through May 22, 2020.