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

 
We decided that the Plan does not have to pay for gym benefits for 2017. 
 
You asked the Plan to pay for gym benefits for 2017. You say that the Plan should pay for these benefits. The 
Plan denied your request. The Plan says there was not a gym benefit for 2017 under the contract you were 
enrolled in.  
 
The rules say that Medicare does not cover gym benefits. In 2017, the Plan contract you were enrolled in did 
not include gym benefits. Therefore, we decided that the Plan does not have to pay for gym benefits for 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis (20611) provided on May 20, 2020. 
 
You asked the Plan to pay for the arthrocentesis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not include 
record of permanently recorded images to support the billed charge. 
 
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 20611 is  arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting. 
 
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 arthrocentesis. Our reviewer says that CPT code 20611 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation did 
not include permanent recording and reporting required to bill for CPT 20611. 
 
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 arthrocentesis have not been met. Therefore, we decided that the Plan does 
not have to pay for arthrocentesis (20611) provided on May 20, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room physician services provided on June 5, 
2020. 
 
You asked the Plan to pay for the emergency room services. You say that these services were medically 
necessary and should be paid. The Plan denied your request. The Plan says this claim cannot be paid since both 
a left and right diagnosis code were reported instead of the bilateral code. 
 
The Plan must follow Medicare rules. Medicare rules say that reporting diagnosis codes for both the left and 
the right side of a condition should only be done if there is no bilateral diagnosis code.  
 
This claim was billed with diagnosis codes M16.11 and M16.12. Since there is a bilateral code for this 
condition, this should have been reported. As such, the claim is not billed in accordance with ICD-10 
guidelines. Therefore, we decided that the Plan does not have to pay for the emergency room physician services 
provided on June 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the powered pressure-reducing air mattress rendered on July 
17, 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 services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a powered pressure-reducing air mattress  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 pay for these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the enrollee has limited mobility with 
advanced cognitive impairment. She is incontinent of both feces and urine and has a risk for impaired 
nutritional status. She was diagnosed with four stage one pressure injuries at the time of ordering the pressure 
relieving surface. The records support that the services were reasonable and 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 pay for the powered pressure-reducing air mattress rendered on July 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forintermittent limb compression device.You asked the Plan to pay forintermittent limb compression device. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation documents no ulcers or lower extremity edema.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers.Therefore, we decided that the Plan does not have to pay forintermittent limb compression device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided to the enrollee on December 10, 
2019 and billed under code G0481. 
 
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 code G0481 (1 Unit) remains not supported. The documentation submitted did not 
include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating 
exactly what tests are to be performed. It is noted multiple attempts were made to obtain additional information 
from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and medical necessity documentation. In this case the 
records provided lack an appropriate physician order. Medicare billing criteria are not met. Therefore, we 
decided that the Plan does not have to pay for testing services provided to the enrollee on December 10, 2019 
and billed under code G0481.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on April 14, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that you require the stockings for venous 
insufficiency. The Plan denied your request. The Plan says the requested gradient compression stockings do not 
meet Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on April 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have bilateral edema. The Plan 
denied your request. The Plan says these compression stockings are only covered when there is a qualifying 
wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6545.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided. 
 
You asked the Plan to waive the copayment for emergency care. You say that the copayment should be waived 
since you were admitted to the hospital. 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 $90 
copayment for emergency care.  
 
The record shows that you were admitted under observation. This is not considered an 
inpatient hospital admission. Therefore, you are responsible to pay the $90 copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
care 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 emergency care provided.
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 enrollee is still in the hospital and it is not safe to 
be released. You say that the enrollee needs physician management with aggressive physical and occupational 
therapy. The Plan denied your request. The Plan says care can safely be received in other settings. 
 
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 that it is not reasonable to expect that the enrollee would be able to fully benefit 
from, nor actively participate in, the intensity of services of an IRF. Our reviewer says that care can safely be 
received in other settings. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a set of thoracic medical branch blocks. 
 
You asked the Plan to pre-approve a set of thoracic medical branch blocks. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a set of thoracic medical branch blocks 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 pre-approve a set of thoracic medical branch blocks. 
Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found you have a 9 month history of low back pain and have had 
sacroiliac joint injections as well as Epidural Steroid Injections. You developed thoracic back pain first 
described in Oct 2020. You then underwent Thoracic Bilateral medical branch blocks. You do not have a 3 
month history of thoracic pain and therefore, does not meet the requirement of the LCD. 
 
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 set of thoracic medical branch blocks have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a set of thoracic medical branch blocks.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha. 
 
You asked the Plan to pre-approve Repatha. You say that Repatha is indicated to reduce the risk of myocardial 
infarction, stroke and coronary revascularization. You say that Repatha is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha.  
 
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
documentation does support that you require skilled nursing or skilled therapy services in the SNF setting. Our 
physician reviewer found you have COVID-19 infection. You received oral medications and insulin. You had 
intermittent fever, tachycardia and elevated respiratory rate. You used oxygen via nasal cannula which was 
increased from 2 to 3 liters via nasal cannula.  Her diet was changed to nectar thickened liquids due to 
coughing while drinking. You had wheezing / crackles/rales noted on lung exam and occasional labored 
breathing. You were treated with antibiotics. The documentation does support that you require the specialized 
skills, knowledge, or judgment of a skilled professional nurse to safely and effectively provide medically 
necessary and reasonable treatment. The documentation does support that skilled nursing or skilled therapy 
services are required on a daily basis. As a practical matter, you do require the necessary services on an 
inpatient basis, at a SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia (01215) provided on March 7, 2020. 
 
You asked the Plan to pay for the anesthesia. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation does not support the service billed. 
 
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 01215 is anesthesia for open procedures involving hip 
joint; revision of total hip arthroplasty. 
 
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 anesthesia. Our reviewer says that CPT code 01215 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not 
support a revision of total hip arthroplasty. 
 
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 anesthesia have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia (01215) provided on March 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumbar/Sacral Facet Joint Block. 
 
You asked the Plan to pre-approve Lumbar/Sacral Facet Joint Block. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Lumbar/Sacral Facet Joint Blocks are 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 pre-approve Lumbar/Sacral Facet Joint Block. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic low back pain with some radicular symptoms 
as well as sacro-ilitis. The enrollee has had Physical therapy. The enrollee has also just completed Radiation 
therapy for Breast Cancer. MRI shows multiple pathologies including multi-level spinal stenosis, degenerative 
disc disease as well as facet arthropathy. The enrollee has multiple probable pain generators which have not 
been addressed and therefore, does not meet the criteria of the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lumbar/Sacral Facet Joint Block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Lumbar/Sacral Facet Joint Block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tendon repair (27675) provided April 23, 2019. 
 
You asked the Plan to pay for the procedure. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
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 27675 is Repair, dislocating peroneal tendons; without 
fibular osteotomy. 
 
We find that CPT code 27675 is not supported in the medical record. Specifically, the Operative report does 
not include documentation of a peroneal tendon repair with or without fibular repair. Based on this information, 
we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that 
the Plan does not have to pay for a tendon repair (27675) provided April 23, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for physical therapy provided on June 16, 2020 and June 19, 2020. 
 
You asked the Plan to pay for physical therapy. You say that you were not aware the provider didn't submit 
prior authorization. You say that you are not at fault. The Plan denied your request. The Plan says that there 
was no authorization for these dates of service and the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says that that 
the requested additional therapy on June 16, 2020 and June 19, 2020 is appropriate and accepted as specific and 
effective therapy for the enrollee's condition. Our reviewer says that the specialized skill, knowledge and 
judgment of a qualified therapist was required to establish, design and/or deliver a program to maintain the 
enrollee's current condition or to prevent or slow further deterioration. Our reviewer says that the additional 
sessions allowed instruction and competence in an independent exercise program, increased strengthening 
exercises, and ensured safety with gait. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have been met. Therefore, we decided that the Plan has to pay 
for physical therapy provided on June 16, 2020 and June 19, 2020.  
 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on June 17, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the 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 out of network physician services provided on June 17, 2020.