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

We decided that the Plan does not have to waive the copayment for an outpatient surgery, a CT scan, and an 
inpatient hospital stay provided by participating providers on March 15, 2020, to June 17, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery, a CT scan, and an inpatient hospital stay. 
You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct 
copayments have been 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $350 copayment for outpatient surgery/outpatient hospital facility, a $200 copayment for outpatient 
diagnostic tests/complex radiology, and a $250 copayment per day for days 1-7 per admission for inpatient 
hospital care.  
 
The enrollee has been asked to pay a $350 copayment for an outpatient surgery, a $200 copayment for a CT 
scan, and a $250 copayment per day for days 1-5 per admission for an inpatient hospital stay for a total of 
$1,250 ($250 x 5 days = $1,250). The total amount being asked to pay is $1,800 ($350 + $200 + $1,250 = 
$1,800). An outpatient surgery falls within the outpatient surgery/outpatient hospital facility benefit category, a 
CT scan falls within the outpatient diagnostic tests/complex radiology, and an inpatient hospital stay falls 
within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an outpatient surgery, a CT scan, and an inpatient hospital stay provided by participating 
providers on March 15, 2020, to June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Erector Spinae Block (64999) provided on April 9, 2020. 
 
You asked the Plan to pay for the Erector Spinae Block. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this service was reported without a revenue 
or CPT code description. 
 
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 64999 is unlisted procedure, nervous system. 
 
We asked our coder 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 Erector Spinae Block. Our reviewer says that CPT codes 
64999 does not meet criteria for billing or reimbursement consideration. Our reviewer found ESP Lumbar 
injection would not be reported with CPT 64999.  A more appropriate code to report would be CPT 64461. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Erector Spinae Block have not been met. Therefore, we decided that the 
Plan does not have to pay for the Erector Spinae Block (64999) provided on April 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one (1) dental extraction to be performed by an Oral 
Surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the service is not a covered benefit under the plan when 
performed by anyone other than a participating general dentist. 
 
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. 
 
Review of the file show that you are requesting one (1) dental extraction to be performed by an Oral Surgeon. 
Services by an oral surgeon are not covered. Your EOC states that services must be performed by a 
participating general dentist. Therefore, we decided that the Plan does not have to pre-approve one (1) dental 
extraction to be performed by an Oral Surgeon.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the 
enrollee from April 30, 2020 to May 29, 2020. 
 
You asked the Plan to pay for the SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee required no nursing services which would be considered 
skilled services by Medicare. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. 
 
Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from April 30, 2020 to 
May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization procedure provided on February 25, 
2020 billed with CPT code 37229-LT. 
 
You asked the Plan to pay for the billed procedure. You say that this was billed correctly and should be paid. 
The Plan denied your request. The Plan says review of the operative report does not support the reporting of 
this code. 
 
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 37229 is Revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the 
same vessel, when performed. 
 
We asked our coding 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 billed procedure. Our reviewer says that 
the operative report does not support the procedure as billed. Our coding reviewer found while the operative 
report does document that a revascularization was initiated, the procedure was terminated. As such, it is only 
payable if reported with modifier 52 for reduced services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the revascularization procedure provided on February 25, 2020 billed with CPT code 
37229-LT.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that it is felt that daily skilled care in the SNF 
is required and was recommended by the treating doctors. The Plan denied your request. The Plan says the 
enrollee's needs are custodial and do not require daily skilled services. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the 
hospital from assisted living on 11/6/2020 with altered mental status. She was treated in the hospital with 
intravenous fluids and ceftriaxone for acute kidney injury and a urinary tract infection. She is weak and 
deconditioned and is working with physical and occupational therapy. She is maximum assist for transfers and 
is not reported to be ambulatory and she requires total assistance for some activities of daily living.  
 
The documentation does not show that the enrollee requires the specialized skill, knowledge and judgment of a 
qualified therapist is not required to safely and effectively provide medically necessary and reasonable 
treatment. The documentation does show that the enrollee does require daily skilled nursing services, namely 
daily intravenous antibiotics through 11/21/2020. However, as a practical matter, the records do not support 
that the patient requires these services to be provided on 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing and/or skilled rehabilitation services 
 
You asked the Plan to pay for skilled nursing and/or skilled rehabilitation services. You say that you are 
physically drained and need help. The Plan denied your request. The Plan says the notes do not show that you 
have a medical problem that only a skilled person can do, so this request has been denied. 
 
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 skilled nursing and/or skilled rehabilitation 
services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are 
no identifiable skilled therapy service needs and you do not require skilled nursing or therapy services on a 
daily basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing and/or skilled rehabilitation services have not been met. 
Specifically, you do not require any skilled therapy services. Therefore, we decided that the Plan does not have 
to pay for skilled nursing and/or skilled rehabilitation 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
diarrhea and failure to thrive. Medical problems are stable. There are no identified problems that need inpatient 
medical management. There are no complex nursing or rehabilitation needs. 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. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoCycle Home FES Cycling Therapy System. 
 
You asked the Plan to pre-approve the equipment. You say that the equipment is necessary. The Plan denied 
your request. The Plan says the Myocycle home FES therapy system is considered exercise equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The Myocycle 
home FES therapy system is considered exercise equipment. Of additional note, based upon a review of the 
medical literature, this type of stationary exercise device is considered unproven to prevent or reduce muscle 
atrophy in upper and lower extremities in individuals with hemiplegia or quadriplegia and other neurological 
indications. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This 
item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve MyoCycle Home FES Cycling Therapy 
System.
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 of LTACH coverage 
should be upheld. The patient is currently undergoing treatment at an ACH for complications following lower 
spine surgery. The patient was intubated/ventilated and subsequently received a tracheotomy. There is no 
evidence that the patient 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 patient to the LTACH. The patient 
can remain at the current ACH until such time no acute services are required. The patient can then be 
transferred/discharged to a lower level of care for any ongoing LTC needs. 
 
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 admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that the enrollee is currently on oxygen and can 
barely breathe. The Plan denied your request. The Plan says this 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. 
Although further rehab services would be appropriate to improve function, as a practical matter, the daily 
skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not 
 
 
have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically 
stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her 
baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab 
services is not 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the continued SNF services. You say that you need continued SNF care. 
The Plan denied your request. The Plan says the rules for SNF care have not been met. 
 
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 the continued SNF services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does 
not require skilled nursing or therapy services on a daily basis.   
 
 
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 continued SNF services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be received in other settings, for example: a skilled nursing facility. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of therapy services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. You say that a third bilateral procedure should 
provide substantial relief. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two thermal RF sessions will be 
reimbursed in any rolling 12-month year. 
 
We looked at the file and Medicare rules. The documentation shows that you received two bilateral 
radiofrequency ablations in September 2020. 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 radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA 1 and 2 testing and BART or large 
rearrangement analysis. 
 
You asked the Plan to pre-approve BRCA 1 and 2 testing and BART or large rearrangement analysis. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not 
meet criteria for the requested testing. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA 1 and 2 testing and BART or large 
rearrangement analysis is only covered for certain indications. 
 
Review of the file shows that the plan uses LCD L36163 to support their denial. However, LCD L36163 is not 
valid for your home state of Florida. Therefore, we cannot use LCD L36163 to substantiate our decision. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of BRCA 1 and 2 testing and BART or large rearrangement analysis have not been met. Therefore, 
we decided that the Plan does not have to pre-approve BRCA 1 and 2 testing and BART or large rearrangement 
analysis.