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

 
We decided that the Plan does not have to pre-approve lumbar epidural steroid injections. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's quality of living has 
declined due to her inability to function without pain. The Plan denied your request. The Plan says there has not 
been a six-month interval since the last injection. 
 
The Plan follows Medicare rules. Medicare rules say that epidural injections are only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of low back pain, secondary to post-laminectomy syndrome. The 
pain radiates to the right hip and lower extremity and is rated 8/10. She has a spinal cord stimulator and also 
uses Hydrocodone for pain relief. The enrollee has had physical therapy and chiropractic treatments. In this 
case, the enrollee has received epidural injections on February 6, 2020, June 26, 2020, and July 30, 2020. The 
records do not show that 6 months has passed since the last series of 3 injections.  Based on the rules and 
records provided, the requested injection is not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Electrocardiogram, routine ECG with at least 12 leads; 
interpretation and report only provided on May 26, 2020. 
 
You asked the Plan to pay for the ECG. You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers.  
 
Payment for this service would have been included under the facility claim. The enrollee was an inpatient for 
this consultation. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we 
decided that the Plan does not have to pay for Electrocardiogram, routine ECG with at least 12 leads; 
interpretation and report only provided on May 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient lift. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a patient lift is covered when specific criteria are 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has multiple sclerosis. The 
progress note dated July 13, 2020 indicates he is weaker, less active, and developing buttock ulcers. He is noted 
to have osteoporosis and is wheelchair-dependent and does not perform weight bearing exercises. The 
documentation does not clearly indicate that without the lift, the enrollee would be bed-confined. The services 
are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a patient lift.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on July 25, 
2019. 
 
You asked the Plan to waive the copayment for specialist services. You say that this was for the testing of the 
device, not your heart. 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 $20 
copayment for specialist visits.  
 
The medical records show that you received specialist services on July 25, 2019. Therefore, you are responsible 
to pay the $20 copayment.  
 
You have been asked to pay a $20 copayment for specialist services. Specialist services fall within the 
physician/practitioner services, including doctor's office visits 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 specialist services provided on July 25, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services provided from August 3, 2019, to 
September 12, 2019. 
 
You asked the Plan to pre-approve home health services. You say that you were told these services did not 
require authorization. The Plan denied your request. The Plan says a physician must certify the need for home 
health services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. The rules also say that the provider, supplier, or beneficiary, as appropriate, must 
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. 
 
We looked at the file and Medicare rules. No medical records, including a physician's certification of the need 
for home health services, have been submitted. Without this information, it cannot be verified that Medicare 
criteria were met. Based on this information, we decided that Medicare rules for coverage of home health 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health 
services provided from August 3, 2019, to September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services related to a spinal allograft 
provided on November 25, 2019 billed with code 20930-AS. 
 
You asked the Plan to pay for the spinal allograft assistant services. You say that the claim should be paid due 
to medical necessity. The Plan denied your request. The Plan says it was found that payment should be made 
for all billed services except for code 20930 which is not separately 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. 
 
CPT code 20930 has a status indicator of "B" in the Physician Fee Schedule. This means that payment is 
always bundled into payment for other services rendered on the same date. Based on this information, we 
decided that Medicare rules for coverage of the spinal allograft assistant services have not been met. Therefore, 
we decided that the Plan does not have to pay for the surgical assistant services related to a spinal allograft 
provided on November 25, 2019 billed with code 20930-AS.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar decompression services. 
 
You asked the Plan to pre-approve the requested services. You say that your pain level is increasing every day. 
The Plan denied your request. The Plan says the requested services are not covered unless the enrollee is in a 
clinical  trial. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous lumbar decompression will be 
covered by Medicare when provided in a clinical study 
 
We looked at the file and Medicare rules. The documentation does not indicate that you are enrolled in an 
approved clinical study. 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 lumbar decompression services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for an ambulance transport (A0429, A0425) provided February 26, 2019. 
 
You asked the Plan to pay for the ambulance transport. You say that the ambulance transport was medically 
necessary. The Plan denied your request. The Plan says that the enrollee was stable enough to be transported by 
other means. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules.  
 
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 the ambulance transport. Our reviewer says 
that the ambulance transport at issue meets coverage criteria. Our physician reviewer found the enrollee was 76 
years old and presented with respiratory symptoms. Respiratory symptoms can change rapidly in this 
population with little reserve function. The enrollee also reported back and chest pain. It is reasonable that a 
prudent layperson would request ambulance transport in this instance. 
 
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 ambulance transport have been met. Therefore, we decided that the Plan has 
to pay for an ambulance transport (A0429, A0425) provided February 26, 2019.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care, and does not require a transfer. 
 
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 physician 
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
bacteremia and new onset renal failure. The enrollee is receiving antibiotics and has been stared on 
hemodialysis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee 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 enrollee to the LTACH. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayments for the testosterone injections you received from January 
6, 2020, through June 8, 2020. 
 
You asked the Plan to waive the copayments for the testosterone injections. You say that you did not receive 
diagnostic services, so this copayment should not apply. The Plan denied your request. The Plan says that you 
were charged these copayments correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay an $80 copayment for diagnostic procedures and tests 
received in an outpatient hospital facility. 
 
The Plan has charged you the total amount for each injection you received because it is less than what they 
claim is the applicable $80 copayment for these services. We do not find this argument persuasive.  The 
records show that on each date of service, you receive a testosterone injection which was coded 940- other 
therapeutic service by the billing facility.  The Plan's Evidence of Coverage explicitly states that the $80 
copayment applies to Diagnostic Procedures and Tests.  The injections you received are neither diagnostic 
procedures nor tests.  Although the Evidence of Coverage states in the heading for the service category on page 
77 includes Outpatient diagnostic tests and therapeutic services and supplies, there is no corresponding cost 
sharing listed for stand-alone therapeutic services such as injections.  We find that the Evidence of Coverage 
does not clearly disclose what the cost sharing obligation would be for stand-alone testosterone injections you 
receive in an outpatient hospital facility. It is the plan's obligation to disclose this. Therefore, we decided that 
the Plan has to waive the copayments for the testosterone injections you received from January 6, 2020, 
through June 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. You say that there are medication changes being made. 
The Plan denied your request. The Plan says the enrollee has improved, and is no longer a threat to self or 
others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued inpatient services were requested from September 30, 2020, forward. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pre-approve continued services. Our physician reviewer found that active 
treatment was not taking place. The services were not reasonably expected to improve the enrollee's condition, 
or for the purpose of diagnosis. This enrollee was treated under an individualized treatment plan, and was 
supervised and evaluated by a physician. Based upon review the records, the enrollee was not shown to be a 
danger to others, but had passive suicidal thought with no plan. She was not showing any visual, but had 
auditory hallucinations, and was cooperative/compliant with treatment while not showing any threats the 
safety. Therefore, the requested continued services are not shown to be 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric 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 you are extremely week and are not able to live at 
home alone. You also say that you will benefit from IRF services. The Plan denied your request. The Plan says 
the IRF services you are requesting do not meet the requirements for approval. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. Our 
physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 you were independent and active before going to the 
hospital. The Plan denied your request. The Plan says there are no medical conditions that require close 
supervision of a rehab physician. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for nausea and vomiting and had abdominal surgery. Your medical 
problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. The medical record supports a need for physical and occupational therapy b,ut it 
does not support a need for an intensive rehabilitation therapy program. 
 
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 spinal fusion surgery. 
 
You asked the Plan to pre-approve spine surgery. You say that you have pinched nerves that cause pain and do 
not understand why this is being denied. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because you are a current smoker with no documentation of smoking 
cessation. 
 
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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show that you are a smoking and there is no documentation of smoking cessation. 
Smoking is a contraindication to fusion surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. The Plan denied your request. The Plan says backup 
chairs are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee provided a wheelchair in December 2019. The requested wheelchair serves the 
same purpose as the wheelchair that has already been provided. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided from November 7, 
2019 to April 8, 2020. 
 
You asked the Plan to pay for home infusion therapy services (S9328). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says this code is not valid for Medicare purposes. 
 
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 S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes 
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare 
uses another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided 
that the Plan does not have to pay for home infusion therapy services provided from November 7, 2019 to April 
8, 2020.