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

 
We decided that the Plan does not have to pay for the surgical services rendered on December 5, 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 procedure codes 15002, 15003, and 15004 are 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 15002 is surgical preparation of recipient site of arm by 
excision of burn eschar, first 1% of body area of infants and children. The definition of code 15003 is surgical 
preparation of recipient site of arm by excision of burn eschar, each additional 100.0 sq cm or less. The 
definition of code 15004 is surgical preparation of recipient site of digit by excision of burn eschar, first 100.0 
sq cm or less. 
 
We find that CPT codes 15002, 15003, and 15004 are not supported in the medical record. Specifically, the 
operative report does not included documentation of surgical preparation or creation of recipient site by 
excision of open wounds, burn eschar, or scar orbits of any size. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the surgical services rendered on December 5, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular studies (93880, 93925) provided on March 2, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON vascular studies. You say that this should be covered. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 has network providers 
available who can provide 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 vascular studies (93880, 93925) provided on 
March 2, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the thoracoscopy (32653) provided on April 8, 2020. 
 
You asked the Plan to pay for CPT code 32653. You say that the medical records support the billing of CPT 
code 32653. The Plan denied your request. The Plan says that the medical records do not support the billing of 
CPT code 32653. 
 
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 32653 is Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for CPT code 32653. Our reviewer says that the 
medical records support the billing of CPT code 32653. Our physician reviewer found based on the operative 
note stating the pleural space was examined and both suction and graspers used is sufficient to support that 
thoracoscopy was employed during the procedure.  Based on the operative note thoracoscopy was performed 
prior to converting the procedure to an open thoracotomy to treat bullous disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT code 32653 have been met. Therefore, we decided that the Plan has to pay 
for the thoracoscopy (32653) provided on April 8, 2020.  
 
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 the surgical services rendered on March 10, 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 13122 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 13122 is repair, complex, scalp, arms, and/or legs; each 
additional 5 cm or less (List separately in addition to code for primary procedure). 
 
We find that CPT code 13122 is not supported in the medical record. Specifically, this is an add-on code that 
was billed without an approved primary procedure code. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the surgical services rendered on March 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) of the chest 
(71250) provided February 5, 2020. 
 
You asked the Plan to waive the copayment for the CT of the chest. You say that you paid a lower copayment 
last year for the same procedure. 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 $100 
copayment for diagnostic imaging.  
 
You have been asked to pay a $100 copayment for the CT of the chest. The CT of the chest falls within the 
diagnostic imaging 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 computed 
tomography (CT) of the chest (71250) provided February 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need these 
transportation trips. The Plan denied your request. The Plan says that this request will exceed he benefit 
allowance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve four (4) additional routine transportation trips.
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 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 IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99327), the therapeutic, prophylactic, or diagnostic injection (96372), urinalysis (81002), and the ceftriaxone sodium injection (J0696) rendered by the out of network (OON) provider on March 22, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99327), the therapeutic, prophylactic, or diagnostic injection (96372), urinalysis (81002), and the ceftriaxone sodium injection (J0696) rendered by the out of network (OON) provider on March 22, 2020.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current setting. Therefore, this request for LTACH services will be considered not 
medically necessary as there is no advantage to transferring at this time. Transfer to a lower level of care may 
be considered when more stable. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. 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 must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from June 29, 2020 to October 
7, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve PET with concurrently acquired CT for attenuation correction and 
anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says that the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our physician reviewer 
found Merkel cell carcinoma is a highly aggressive neuroendocrine tumor of the skin that has a higher 
mortality rate than melanoma. A high proportion of patients succumb to metastatic disease and it is imperative 
that close follow up including routine surveillance with PET scans are performed as this likely changes 
management in a significant number of patients, even asymptomatic patients. You have evidence of recurrent 
disease, most recent being September 2020. You underwent PET scan in April 2020 that did not show evidence 
of distant metastases. It would be medically appropriate to use PET scans every six (6) months for routine 
surveillance for such an aggressive cancer as the literature has shown and supported this treatment course. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
skull base to mid-thigh (CPT Code 78815).  
 
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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The 
patient does not require the intensity of services provided at an IRF. Specifically, the patient is not shown to be 
able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The 
patient's 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 SNF care. 
 
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The patient does not require skilled 
nursing or therapy services on a daily basis. This patient does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on review of available records, the enrollee does not meet criteria for coverage 
for an IRF admission. The patient is generally medically stable with failure to thrive with no evidence of 
complex medical issues that require monitoring by an inpatient Physical Medicine and Rehabilitation (PM&R) 
physician three (3) times per week or need for acute rehab nursing care. The patient needs assist with activities 
of daily living (ADLs) and mobility. While the patient may benefit from continuing physical therapy (PT) and 
occupational therapy (OT), there is no evidence of need for an intensive therapy program with therapy 3 hours 
per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The patient 
had Dementia and it is questionable how much they will carryover from session to session in therapies. 
Admission to IRF is not medically necessary based on lack of medical complexity and need for extensive care. 
The enrollee's rehab needs can be met in an alternate, low intensity setting such as in an SNF. 
 
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: 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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health plan's denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to 
perform fifteen hours per week of rehabilitative services with regular physician evaluation. 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.