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

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (64633) and 
destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); 
cervical or thoracic, each additional facet joint (64634). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, single facet joint and destruction by 
neurolytic agent, each additional facet joint. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency (RF) destruction of cervical, 
thoracic or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically 
reasonable and necessary when specific criteria is met. 
 
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 destruction by neurolytic agent, single 
facet joint and destruction by neurolytic agent, each additional facet joint. Our reviewer says that the services 
are not medically necessary. Our physician reviewer found in this case, the previous RF ablation at the same 
anatomic site did not provide a minimum of 50% improvement in pain for at least six months. The review has 
determined that the enrollee does not meet the coverage criteria. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, single facet joint and destruction by neurolytic 
agent, each additional facet joint have not been met. Therefore, we decided that the Plan does not have to pre-
approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy 
or CT); cervical or thoracic, single facet joint (64633) and destruction by neurolytic agent, paravertebral facet 
joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint 
(64634).
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 SNF services. You say that you require more therapy. The Plan denied your 
request. The Plan says that records show you do not have a need for daily skilled therapy at this time. 
 
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 continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided 
on June 11, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you have paid 
all your bills and should not be responsible for the charges. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on June 11, 2020. The allowed amount is $1,783.60 and 20% of that is 
$356.72.  
 
You have been asked to pay the total coinsurance amount of $356.72 for a Medicare Part B drug injection. A 
Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug injection provided on June 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SYNVISC (J7325). 
 
You asked the Plan to pre-approve SYNVISC. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not met the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SYNVISC. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the request for SYNVISC is not medically 
necessary or reasonable at this point, the patient should be trialed on the preferred medications prior. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SYNVISC have not been met. Specifically, the item requested has step therapy 
requirements that have not been met. Therefore, we decided that the Plan does not have to pre-approve 
SYNVISC (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on September 15, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
referring provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on September 15, 
2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on August 31, 2020. 
 
You asked the Plan to pay for the surgery. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 
surgery. 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 surgery provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, each additional 30 minutes (99292x3) provided 
May 20, 2020. 
 
You asked the Plan to pay for the critical care services. You say that please reprocess this claim for payment. 
You have updated the full medical records. The Plan denied your request. The Plan says the records do not 
support the billed service. 
 
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  is critical care, each additional 30 minutes). 
 
We find that CPT code 99292x3  is not supported in the medical record. Specifically, the submitted medical 
records do not include a critical care evaluation and management note supporting 75 minutes or more of critical 
care. This is an add-on type code. An add-on code is eligible for payment only if it is reported with an 
appropriate primary procedure performed by the same practitioner. An add-on code is never eligible for 
payment if it is the only procedure reported by a practitioner. Based on this information, we decided that 
Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan 
does not have to pay for critical care, each additional 30 minutes (99292x3) provided May 20, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on March 4, 
2019. 
 
You asked the Plan to pay for the physician service. You say that you did not receive proper notice of the 
enrollee's benefit determination, hence, the untimely submission of the claim. You also say that you would like 
for the claim to be reprocessed and paid. The Plan denied your request. The Plan says Medicare denies a claim 
if it is not received by the plan within 12 months or 1 calendar year from the date when the services were 
rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician service was not filed until September 8, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on March 4, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
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 the enrollee's current needs can be met at an alternate 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 the enrollee's condition does not 
meet Medicare criteria for continued 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 continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound examination provided. 
 
You asked the Plan to waive the copayment for ultrasound. You say that a Plan representative told you that due 
to COVID-19 there would be no copayment for this test. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
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 $110 
copayment for in-network ultrasound.  
 
You have been asked to pay $110 copayment for ultrasound. Ultrasound falls 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 an ultrasound examination provided.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve complete shoulder joint replacement for the enrollee. 
 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically 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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted with persistent, progressing right shoulder pain. Enrollee is now unable to sleep 
throughout the night, secondary to pain. The shoulder is diffusely painful. He is unable to lift objects at this 
point, which is significantly limiting in his daily life. He notes bilateral hand numbness. The entire hand is 
numb. Exam reveals right shoulder abduction 150, internal rotation to lumbar spine, and external rotation to 70. 
Strength is 4+/5 on rotator cuff testing of the supraspinatus, infraspinatus and 5/5 subscapularis muscles, empty 
can and resisted internal/external rotation testing. There is positive Popeye deformity. X-rays are noted to show 
severe glenohumeral degenerative joint disease with subacromial impingement. Provided documentation 
demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial and failure of 
conservative treatment modalities has been documented. The patient is not a candidate for a cuff repair; The 
rotator cuff motor function is overall weak however. The motor function of the deltoid muscle appears intact 
and motion is acceptable for a reverse total shoulder replacement. This enrollee is a candidate for reverse 
shoulder arthroplasty, as there is well documented arthritis of the glenohumeral joint. Therefore, the requested 
complete shoulder joint replacement is medically reasonable and 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 the surgery have been met. Therefore, we decided that the Plan has to pre-
approve complete shoulder joint replacement for the enrollee. 
  
 
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: Favorable

 
We decided that the Plan has to pre-approve cervical facet blocks (64491, 64490). 
 
You asked the Plan to pre-approve cervical facet blocks. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
has not been met. 
 
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 cervical facet blocks. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found one progress note states the pain radiates into her arms but she also has stocking and glove 
neuropathic pain. A subsequent note states no dermational radiation. Therefore, the request is medically 
reasonable and 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 cervical facet blocks have been met. Therefore, we decided that the Plan has to 
pre-approve cervical facet blocks (64491, 64490).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 11, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that the ordering physician determined that this testing 
was medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is 
correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network 
with the Plan. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on September 11, 
2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on September 28, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
referring provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on September 28, 
2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on January 1, 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 filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until November 3, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services rendered on January 1, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home therapy services received. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is an invalid procedure code for this service. 
 
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 99601 and HCPCS S9810 is not supported in the medical record. Specifically, these 
codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the 
codes are not valid for Medicare purposes. 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 home 
therapy services received.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a visit to the emergency room (99284) 
provided on September 27, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to an urgent 
care facility, not an emergency room. The Plan denied your request. The Plan says that the facility in question 
is classified as an emergency department and the visit was billed as a visit to an emergency room. Emergency 
care is subject to a $90 copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. We found that the facility in 
question is classified as an emergency department. An emergency room visit falls within the emergency care 
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 visit to the emergency room 
(99284) provided on September 27, 2020.