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

 
We decided that the Plan does not have to issue reimbursement for the home health aide services (S9122) 
provided from February 1, 2020, through February 29, 2020. 
 
You asked the Plan to issue reimbursement 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 Medicare 
hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to 
the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending 
physician services and all care unrelated to the terminal illness until the first day of the month following the 
month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to issue reimbursement for the home health aide services (S9122) 
provided from February 1, 2020, through February 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopedic services provided to the enrollee on July 21, 2020 
and billed under code 29580. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the anatomic-specific modifiers LT (Left side), RT (Right side), and 50 (Bilateral 
procedure) designate the area or part of the body on which the procedure is performed. These modifiers are 
required whenever they are appropriate. If a procedure that is defined as requiring an anatomical modifier 
indicating the side of the body on which it is performed is billed without an associated LT (Left side), RT 
(Right side), or 50 (Bilateral procedure) anatomical modifier, then deny the procedure . In this case the claim 
submitted does not include the required modifier. Medicare billing criteria are not met. The Plan states a 
corrected claim was requested and received for reprocessing.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when necessary the appropriate modifiers. In this 
case, the original claim submitted lacks the required modifier. Medicare rules for coverage of this service have 
not been met. Therefore, we decided that the Plan does not have to pay for orthopedic services provided to the 
enrollee on July 21, 2020 and billed under code 29580.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from December 2, 
2019, to December 31, 2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from December 2, 2019, to December 31, 
2019.
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 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 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 enrollee 
does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. The enrollee'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 
inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81162, 81201, 81203, 81242, 81292, 81294, 
81295, 81297, 81298, 81300, 81317, 81319, 81321, 81323, 81404, 81405, 81406, 81407, 81408) provided 
December 9, 2019. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 81162, 81201, 81203, 81242, 81292, 81294, 81295, 81297, 81298, 81300, 81317, 
81319, 81321, 81323, 81404, 81405, 81406, 81407, & 81408 are not supported in the medical record. 
Specifically, the place of service listed on the claim does not match the place of service noted in the medical 
records. The plan requested additional documentation for clarification and it was not provided. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81162, 81201, 81203, 81242, 81292, 81294, 81295, 
81297, 81298, 81300, 81317, 81319, 81321, 81323, 81404, 81405, 81406, 81407, 81408) provided December 
9, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for laboratory services provided on June 18, 2020. 
 
You asked the Plan to hold you harmless for the laboratory services. You say that you would like 
reconsideration because you are being billed for these lab services. The Plan denied your request. The Plan says 
that this is not a Medicare covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for laboratory services provided on June 18, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the whirlpool walk in bath received on May 21, 2020. 
 
You asked the Plan to pay for the whirlpool walk in bath. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the item received was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a whirlpool walk in bath is only covered for certain 
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 pay for the whirlpool walk in bath. Our reviewer 
says that the documentation does not support that the item received was medically reasonable or necessary. Our 
physician reviewer found you have a medical history of a stroke and chronic pain and are having trouble 
getting into and out of your bathtub. The documentation does not support that you are homebound. The 
documentation does not support that you have a condition for which the whirlpool bath can be expected to 
provide substantial therapeutic benefit justifying its cost. Therefore, you did not meet criteria for the item 
received. 
 
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 whirlpool walk in bath have not been met. Therefore, we decided that the 
Plan does not have to pay for the whirlpool walk in bath received on May 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 5, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation submitted does not include a valid physician order, lab requisition, or medical records for the 
tests billed and does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on November 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on May 1, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 1, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on May 
1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Decipher Prostate Biopsy testing. 
 
You asked the Plan to pre-approve Decipher Prostate Biopsy testing. You say that you want to appeal this 
decision. The Plan denied your request. The Plan says the denial of authorization for this testing is correct. 
 
The Plan follows Medicare rules. Medicare rules say that Decipher Prostate Biopsy testing is only covered 
when the above clinical criteria have been 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 Decipher Prostate Biopsy testing. Our 
reviewer says that you do not meet the Medicare criteria for this testing. Our physician reviewer found the 
estimated life expectancy is not 10 years or greater for your age with chronic obstructive pulmonary disease 
(COPD), hypertension, and hyperlipidemia, which excludes coverage of this testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Decipher Prostate Biopsy testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Decipher Prostate Biopsy testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a third level paravertebral facet injection (64495) provided 
on May 6, 2020. 
 
You asked the Plan to pay for a third level paravertebral facet injection. You say that this is supported in the 
records. 
 The Plan denied your request. The Plan says a third level is not documented. 
 
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 64495 is injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary 
procedure). 
 
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 a third level paravertebral facet injection. 
Our reviewer says that this code is not supported. Our physician reviewer found the medical records support 
only 2 levels of injections. 
 
 
 
 
 
 
 
 
 
 
 
 
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 third level paravertebral facet injection have not been met. Therefore, we 
decided that the Plan does not have to pay for a third level paravertebral facet injection (64495) provided on 
May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on June 12, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the medical records show the enrollee had surgical pathology of skin lesions on June 12, 
2020. The submitted documentation supports 3 (three) units of 88305 and 1 (one) unit of 88304, which were 
previously approved and paid.  There is no additional documentation supporting additional studies which were 
billed and remain denied. The reports submitted are duplicates of each other.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide records that support the services billed. 
In this case the claim submitted cannot be paid due to previous payment for the same services, for the same 
enrollee on the same date of service. Medicare billing criteria are not met. Therefore, we decided that the Plan 
does not have to pay for physician services provided to the enrollee on June 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.

You asked the Plan to pre-approve the requested services. You say that the injections are very helpful. The Plan denied your request. The Plan says the request exceeds the allowed limit.

The Plan follows Medicare rules. Medicare rules say that lumbar 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 you have lumbar spinal stenosis with neurogenic claudication. You had an epidural steroid injection, which provided 60-70% relief for 3 months. You denied numbness, tingling, or weakness in the bilateral lower extremities. The physical exam was essentially normal. You continue with low back pain.  Presently there are no documented radicular signs, signs of nerve compression on the exam, and no magnetic resonance imaging scan documented. Furthermore, there is no documentation of failure of four weeks (counting from onset of pain) of non-surgical, non-injection care. Based on the rules and records provided, you do not meet the coverage criteria for the requested injection. Therefore, the requested service is not considered 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 a lumbar epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost share for the physician services provided from April 
29, 2020, to May 2, 2020. 
 
You asked the Plan to adjust the cost share for the physician services. You say that the services did not occur. 
The Plan denied your request. The Plan says the claims were applied to your deductible and processed 
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 there is a $198 deductible for your out-of-pocket costs for covered services and 
a 20% coinsurance for services in a specialist?s office.  
 
The item or service you asked the Plan to adjust the cost share for falls within the benefit category your out-of-
pocket costs for covered services. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $198 deductible for your out-of-pocket costs for covered services and a 20% coinsurance for 
specialist services. This deductible is a contractual obligation that had not been met at the time the physician 
services were received from April 29, 2020, to May 2, 2020. Therefore, we decided that the Plan does not have 
to adjust the cost share for the physician services provided from April 29, 2020, to May 2, 2020. Your 
complaint is not a valid appeal for medical coverage. Your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to issue reimbursement for the retinal imaging provided on July 25, 2020. 
 
You asked the Plan to issue reimbursement for the retinal imaging. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that this service 
is not a covered benefit under your contractual policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request as the Evidence of Coverage booklet indicating the Plan contract has not been 
provided. Therefore, we decided that the Plan has to issue reimbursement for the retinal imaging provided on 
July 25, 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the computed tomography (CT) scan, thorax; without contrast 
material (CPT Code 71250). 
 
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your 
request. The Plan says that repeat imaging is only supported one (1) year after your nodule(s) were found. The 
Plan states if the nodule is unchanged on the one-year study, no further imaging is supported. The Plan states 
your records do not describe this imaging time frame. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our physician reviewer 
found following nodules with scans annually is appropriate. In this case, the number of nodules did change 
between the scans, therefore, should not be considered stable and more frequent scanning is justified. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve the CT scan, thorax; without contrast material (CPT Code 71250).  
 
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.