Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) provided on March 12, 
2020 to March 18, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you had a heart attack while in NY City 
and was admitted into the hospital. You were released with vision difficulty and went to have your vision 
checked. You are not able to travel due to COVID-19. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 outpatient office visit (99203) provided on 
March 12, 2020 to March 18, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral joint epidural steroid injection. 
 
You asked the Plan to pre-approve a sacral joint epidural steroid injection. 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 sacral joint epidural steroid injection. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the physical exam did not document tests such as hip posterior thrust 
test, Gaenslen test, FABERE test, lateral compression and distraction of the pelvis, which would distinguish 
sacroiliac (SI) joint pathology from other etiologies of lumbosacral pain. No imaging studies of the sacroiliac 
joint indicative of spondyloarthropathy were provided. Based upon the submitted medical records, coverage for 
the requested procedure is not 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 a sacral joint epidural steroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a sacral joint epidural steroid injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion testing (SPECT 
scan) you had on June 24, 2020. 
 
You asked the Plan to waive the copayment for the SPECT scan. You say that on June 23, 2020, you went to 
the Emergency room.  You said that the doctor there referred you for a stress test, so it should be included in 
your emergency room copayment. 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 $250 
copayment for nuclear medicine services.  
 
You have been asked to pay a $250 copayment for the SPECT scan. The SPECT scan falls within the nuclear 
medicine services benefit category. This testing was not performed as part of your Emergency room visit- it 
was billed separately on a different date of service. 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 myocardial perfusion testing (SPECT scan) you had on June 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIRF care to be provided by an out-of-network provider.You asked the Plan to pre-approvethe services. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approveIRF care to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean upper endoscopy for the enrollee. You asked the Planto pre-approvethe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary and appropriate at this time.The Plan must follow Medicarerules. 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 the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available records do not describe endoscopic findings in 2019 that require histologic reassessment. The enrollee is not presently symptomatic relative to GERD, and does not require acid-blocker therapy 1-year post-operative to her Nissen fundoplication and hernia repair. The coverage criteria as provided for a medically necessary EGD are not presently met based on the documents received and reviewed.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 testing have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean upper endoscopy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
needs can be met at an alternate 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent, paravertebral facet 
joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and 
destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); 
lumbar or sacral, each additional facet joint (64636). 
 
You asked the Plan to pre-approve nerve treatment. You say that you request for approval for the 
radiofrequency ablation procedure before the next approved 6 month interval for coverage. The Plan denied 
your request. The Plan says it has only been 4 1/2 months since the last injection. Not enough time has elapsed 
for a repeat denervation procedure. This procedure cannot be performed until a minimum of 6 months has 
elapsed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of nerve treatment have not been met. Therefore, we decided that the Plan does not have to pre-
approve the destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional 
facet joint (64636).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued psychiatric hospitalization. 
 
You asked the Plan to pre-approve continued psychiatric hospitalization. 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 continued psychiatric hospitalization. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based upon review of the records provided, the enrollee does not meet 
the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of October 
21, 2020 forward and could have been treated in a lesser restrictive setting. The enrollee was not showing any 
suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors 
or aggression. The enrollee was being cooperative and compliant while not showing any acute threats to the 
safety of himself or others. 
 
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 psychiatric hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued psychiatric hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the biopsy you had at an outpatient hospital 
facility on July 22, 2020. 
 
You asked the Plan to waive the copayment for the biopsy. You say that you don't believe surgery was actually 
done because they just used a needle to collect the samples. 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 $225 
copayment for surgery performed in an outpatient hospital setting.  
 
You have been asked to pay a $225 copayment for the biopsy. The biopsy falls within the outpatient surgery 
benefit category. Biopsies are considered surgical 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 the biopsy you had at an outpatient hospital facility on July 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammography (77066) and a 
diagnostic digital breast tomosynthesis (G0279) performed on June 8, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammography and a diagnostic digital breast 
tomosynthesis. You say that these services should be charged as a routine screening mammography 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 $30 
copayment for each basic imaging service.  
 
You have been asked to pay a $30 copayment for a diagnostic mammography and a diagnostic digital breast 
tomosynthesis. Diagnostic procedures are distinct from routine screening procedures. A diagnostic 
mammography and a diagnostic digital breast tomosynthesis fall within the "Outpatient diagnostic tests and 
therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
diagnostic mammography (77066) and a diagnostic digital breast tomosynthesis (G0279) performed on June 8, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered from March 7, 2020 to 
March 8, 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 99291 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care spent on the enrollee. 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 critical care services rendered from March 7, 2020 to March 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe established patient assisted living visit (99334) provided on July 9, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe established patient assisted living visit. You say that the care you provided was medically necessary.The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.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 providersavailable 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 nothave to pay forthe established patient assisted living visit (99334) provided on July 9, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup and dental bridge. 
 
You asked the Plan to pre-approve the dental services. You say that the existing bridge needs to be replaced to 
restore proper chewing abilities. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core 
buildup and dental bridge.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee would benefit from continued physical therapy and occupational therapy at a lower level of care with a slower pace.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. There is no evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. The documentation does not support that there is a need for an intensive therapy program with 3 hours a day at current levelof function and activity tolerance and an interdisciplinary approach to rehab care. The enrollee is not expected to make a significant functional recovery in an IRF at the current pace and will not tolerate IRF intensity of therapies. His rehab needs can be safely and effectively met in an alternate, less intense setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 85027, 80053, 36415 and the 
travel allowance coded P9603. 
 
You asked the Plan to pay for the laboratory services and the travel allowance. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 codes 85027, 80053, 36415, and P9603 are not supported in the medical record. Specifically, 
the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen 
was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place 
of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen 
was obtained in an office setting place of service 11. The documentation submitted did not include 
documentation of travel allowance including travel mileage, and documentation of homebound status; 
therefore, code P9603 is not supported. Based on this information, we decided that Medicare rules for coverage 
of the laboratory services and the travel allowance have not been met. Therefore, we decided that the Plan does 
not have to pay for the laboratory services coded 85027, 80053, 36415 and the travel allowance coded P9603.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain stem 
rendered on March 11, 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 the billed ICD-10 diagnosis code was a manifestation code. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be 
billed with the most precise diagnosis code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with diagnosis code F02.80, 
which is a manifestation 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 magnetic 
resonance imaging (MRI) of the brain stem rendered on March 11, 2020.
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 the patient appears to be unstable and will require additional acute care services at 
this time which can be safely and effectively completed at the current facility. The patient does not require 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that the patient requires that are not already available and covered at the current setting. Therefore, this request 
for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care at 
a later date may be considered when treatment is completed and the patient is 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 LTACH services.