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

We decided that the Plan has to pre-approve transperineal placement of biodegradable material, peri-prostatic, 
single or multiple injection(s), including image guidance, when performed (CPT Code 55874). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the NCCN Guidelines Version 2.2020 Prostate Cancer page PROS-E 1 of 5 states that 
biocompatible and biodegradable perirectal spacer materials may be implanted between the prostate and the 
rectum in patients undergoing external radiotherapy with organ-confined prostate cancer. The guideline states 
that a randomized phase III trial demonstrated reduced rectal bleeding. Therefore, in the opinion of this 
reviewer, the requested procedure is medically reasonable and necessary for the enrollee. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), 
including image guidance, when performed (CPT Code 55874).  
 
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 a 3D imaging rendering (73676) provided June 30, 2020. 
 
You asked the Plan to pay for the 3D imaging rendering. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the billed code did not include a valid supporting code. 
 
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 73676 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality. 
 
We find that CPT code 73676 is not supported in the medical record. Specifically, CPT code 93318 is not a 
valid supporting code for CPT code 73676. Based on this information, we decided that Medicare rules for 
coverage of the 3D imaging rendering have not been met. Therefore, we decided that the Plan does not have to 
pay for a 3D imaging rendering (73676) provided June 30, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from March 1, 2020, to March 26, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that no one ever told you that you 
would have a copayment for this stay. 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 $0 
copayment per day for days 1-20, and a $178 copayment per day for days 21-100 for skilled nursing facility 
care 
 
Records show that you were in a covered SNF stay from February 1, 2020, to March 26, 2020. According to 
your contract, you have a $0 copayment for days 1-20.  That means that from February 1, 2020, to February 20, 
2020, you had no copayment.  For February 21, 2020, to February 29, 2020, you were charged a copayment of 
$178 per day.  These February dates of service are not included in this case-- this case is only addressing the 
copayments owed in March of 2020.  From March 1, 2020 to March 26, 2020, you were charged a $178 
copayment per day. 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 skilled nursing facility (SNF) 
services provided from March 1, 2020, to March 26, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF stay. 
 
You asked the Plan to pre-approve the SNF stay. The Plan denied your request. The Plan says the SNF services 
you are requesting do not meet the requirements for approval. 
 
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 the SNF stay. Our reviewer says that 
you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the cone beam CT image capture with field of 
view of both jaws (D0383), the abutment supported fixed mandibular denture (D6115), the consultation 
(D9310) and 11 extractions (D7140) provided from November 5, 2018 to November 26, 2018. 
 
You asked the Plan to reimburse you for the cone beam CT capture, the consultation and 9 additional 
extractions. You say that this is not good enough. The Plan denied your request. The Plan says the cone beam 
CT is not listed as a covered service. The Plan says that consultation is not listed as a covered service either. 
The Plan says 2 extractions per calendar year are covered. The Plan also says that the frequency limit has been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT capture and 
consultation are not among those covered under this benefit. Additionally, the frequency limit of 2 extractions 
per calendar year has been exhausted. The record shows that the Plan paid for 2 extractions that you received 
on this date of service. Therefore, we decided that the Plan does not have to reimburse you for the cone beam 
CT image capture with field of view of both jaws (D0383), the abutment supported fixed mandibular denture 
(D6115), the consultation (D9310) and 11 extractions (D7140) provided from November 5, 2018 to November 
26, 2018.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the requested services. You say that you are not able to bath yourself due to 
restricted body movement. The Plan denied your request. The Plan says home health aide services are only 
covered when skilled services are being received. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file, and Medicare rules. Custodial care, such as bathing is not covered. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs can be met by the use of the existing walker or rollator. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not reveal a personal mobility deficit that impairs participation in MRADLs in the home. Your deficit is 
currently helped by a walker and rollator. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
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 you need restorative therapy to regain sufficient 
mobility. The Plan denied your request. The Plan says you are at a custodial 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 physician reviewer 
found that from a nursing perspective, you have stable vital signs, and received oral and ophthalmic 
medications. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a 
minimal assist level with functional mobility. You require varying assist with activities of daily living. 
Although there are identifiable skilled therapy services, 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 skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dressing change (15852) provided on June 6, 2019. 
 
You asked the Plan to pay for the dressing change (15852). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly and 
facility-only codes are identified by a ?NA? in the ?NA Indicator? field. 
 
We find that CPT code 15852 is not supported in the medical record. Specifically, this code has a ?NA? in the 
?NA Indicator? field, indicating it is a facility-only code, but it was billed with POS 11, a non-facility place of 
service. Based on this information, we decided that Medicare rules for coverage of the dressing change (15852) 
have not been met. Therefore, we decided that the Plan does not have to pay for the dressing change (15852) 
provided on June 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is 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 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 based on the documentation provided, the health plan's denial of LTACH coverage 
should be upheld. The patient is currently undergoing treatment at an ACH for a pacemaker pocket infection. 
The patient is not intubated/ventilated. There is no evidence that the patient requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the patient to the LTACH. The patient can remain at the current ACH until such time 
no acute services are required. The patient can then be transferred/discharged to a lower level of care for any 
ongoing LTC needs. 
 
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 LTACH 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. You say that the enrollee continues to require moderate assist 
with ambulation, and daily nursing care. The Plan denied your request. The Plan says the enrollee is 
progressing well with therapy, and is tolerating intensive rehab programs. 
 
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 the most recent therapy notes indicate the enrollee is able to ambulate up to 37 feet with a platform 
rolling walker and assistance. He is able to self-propel a wheelchair, and is able to accomplish bed mobility and 
transfers with minimal assistance. He is able to accomplish most activities of daily living with stand by 
assistance or minimal assistance. He has stabilized medically and has been receiving skilled rehab services in 
an inpatient rehabilitation facility (IRF). He is making good progress with therapy.  
 
There is no indication that transfer to a skilled nursing facility is required. There are no services offered at a 
SNF that are not offered at an inpatient rehab facility. Therefore, an admission to a SNF for inpatient skilled 
rehab services is not medically necessary. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on 
August 10, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a routine 
colonoscopy because there were no findings and no polyps removed. The Plan denied your request. The Plan 
says this was a diagnostic colonoscopy, so the copayment was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery.  
 
You have been asked to pay a $250 copayment for the diagnostic colonoscopy. Medical records show that this 
colonoscopy was ordered due to bloody stools.  Because the doctor requested this test to evaluate this 
symptom, it is considered a diagnostic colonoscopy. The diagnostic colonoscopy falls within the outpatient 
surgery 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 the diagnostic colonoscopy 
you had on August 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider on June 29, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you do not agree with 
this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $275 
copayment for outpatient surgery/outpatient hospital.  
 
You have been asked to pay a $275 copayment for a diagnostic colonoscopy. The rules say that, if during the 
course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the 
growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be 
billed. A diagnostic colonoscopy falls within the outpatient surgery/outpatient hospital 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 diagnostic colonoscopy provided by a participating 
provider on June 29, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on June 25, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges 
because you thought your first colonoscopy was supposed to be fully covered. 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 $250 
copayment for outpatient surgery.  
 
The medical records show that you received a diagnostic colonoscopy on June 25, 2020 due to a positive 
Cologuard test. Therefore, you are responsible to pay the $250 copayment.  
 
  
You have been asked to pay a $250 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
surgery 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 colonoscopy provided on 
June 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services. 
 
You asked the Plan to pre-approve physical therapy services. You say that the enrollee is at risk for falls due to 
functional decline. The Plan denied your request. The Plan says the skills of a therapist are not needed to 
maintain the enrollee's current function. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy services. Our 
physician reviewer found that the requested additional therapy is not generally accepted as specific and 
effective for the enrollee's condition. The enrollee has had extensive therapy for this condition. His functional 
level does not require the ongoing unique skills of a professional therapist to safely and effectively provide 
treatment. The services do not require the skills of a therapist or need to be under a therapist's supervision. The 
enrollee does not require the specialized skill, of a qualified therapist to establish or deliver a program, to 
maintain his condition, or to prevent or slow deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued physical therapy services.