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

 
We decided that the Plan does not have to waive the copayment for injections of anesthetic and/or steroid drug 
into lower or sacral spine nerve root using imaging guidance (64483, 64484) provided on June 3, 2021. 
 
You asked the Plan to waive the copayment for injections of anesthetic and/or steroid drug into lower or sacral 
spine nerve root using imaging guidance. You say that want to know why this was not covered, because they 
are in-network and was part of a procedure. The Plan denied your request. The Plan says you were charged the 
correct cost sharing amount. 
 
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 $1,000 deductible which applies to outpatient hospital services.  
 
You have been asked to pay $175.93 for injections of anesthetic and/or steroid drug into lower or sacral spine 
nerve root using imaging guidance. Injections of anesthetic and/or steroid drug into lower or sacral spine nerve 
root using imaging guidance falls within the Outpatient Hospital Services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time 
injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance was 
received on June 3, 2021. Therefore, we decided that the Plan does not have to waive the copayment for 
injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance 
(64483, 64484) provided on June 3, 2021.
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. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be requiring short-term additional acute care services for 
additional stability that can safely be administered at the current facility until more appropriate for transfer. 
There are no services at the LTACH that the enrollee requires that are not already available at the current 
facility. Transfer may be considered when treatment has completed. 
 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care received on May 25, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the plan does not have out-of-network benefit coverage. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 vision care received on May 25, 2021.
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 you feel that you require SNF care at this 
time. The Plan denied your request. The Plan says you do not require skilled care on a daily basis. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 beneficiary is a female with a 
recent right hip fracture. From a nursing perspective, the beneficiary received oral medications and had stable 
vital signs. Regarding rehabilitation services, the beneficiary received physical and occupational therapy. The 
beneficiary was at a minimal to moderate to maximal assist level for functional mobility or a mechanical lift for 
transfers. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
This beneficiary does not meet severity of illness or intensity of service criteria for 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology and an office visit provided on 
November 30, 2021. 
 
You asked the Plan to pay for diagnostic radiology and an office visit. You say that the x-rays are an essential 
diagnostic tool to diagnose your pain and the office visit was necessary. The Plan denied your request. The 
Plan says services other than manipulations are not covered by your healthcare Plan when billed by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for diagnostic radiology and an office visit provided on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight Psychotropic testing provided on June 23, 
2021. 
 
You asked the Plan to pay for the Genesight Psychotropic testing. You say that this is a covered test. The Plan 
denied your request. The Plan says this testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PGx testing may be indicated when there is intent to 
prescribe a medication for which there is a known gene-drug interaction that is clinically actionable.  
 
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 Genesight Psychotropic testing. Our 
reviewer says that the testing is not shown to be medically necessary in this case. Our physician reviewer found 
the patient stated that she was considering augmenting therapy with a new medication; however, the 
medication(s) being considered where not listed in the documentation. There was insufficient clinical 
documentation provided describing how these test results would lead to a significant improvement in overall outcome to support this request. Therefore, without the list of considered medications and the potential genetic 
issues related to such the LCD criteria has not been met.  
 
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 Genesight Psychotropic testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the Genesight Psychotropic testing provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on  
October 18, 2021, billed with global code 88305. 
 
You asked the Plan to pay for the pathology services as billed. You say that this testing is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the enrollee was a hospital outpatient 
on this date of service so only the professional component of code 88305 is payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the TC of physician pathology services is not 
payable to the physician for services provided to hospital outpatients. 
 
 
 We looked at the file and Medicare rules. The enrollee was a hospital outpatient. The code was billed globally 
for both the professional component and TC, which is not allowed per Medicare billing rules. Based on this 
information, we decided that Medicare rules for coverage of the pathology services as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgical pathology services provided on 
October 18, 2021, billed with global code 88305.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for plastic surgical services provided to the enrollee on July 16, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do 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 14040 is "Adjacent tissue transfer or rearrangement, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report describes a 
complex closure. In this case, CPT 14040 cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for plastic surgical services provided to the enrollee on July 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 1, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use in this case. 
 
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 22315 is "Closed treatment of vertebral fracture(s) and/or 
dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or 
traction." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, CPT 22315 cannot be 
verified by procedure report.  
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on October 1, 2021.
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have 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 in the Medicare rules section. 
 
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 the patient was admitted for right sided weakness and numbness. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable 
expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
September 14, 2021, to September 24, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was overpaid.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 853 (INFECTIOUS AND PARASITIC 
DISEASES WITH O.R. PROCEDURE WITH MCC). 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 services. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found there was no clinical or laboratory evidence of sepsis. The more 
appropriate DRG would be 579: OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES 
WITH MCC.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from September 14, 2021, to September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve medical services. You say that this care is superior to the care you are 
currently receiving. The Plan denied your request. The Plan says there are in-network options available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
medical services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care from April 11, 2022, 
forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that this care is 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for inpatient 
mental health care have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continuation of inpatient mental 
health care. Our reviewer says that the continuation of inpatient mental health care is not medically reasonable 
and necessary. Our physician reviewer found you are an 84-year-old male who was admitted to the acute 
inpatient psychiatric hospitalization on April 4, 2022, with Major Depressive Disorder, Single Episode without 
Psychotic Features. Based upon review the records provided it was not expected that you would improve in a 
reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or 
others, no auditory or visual hallucinations and no aggressive behaviors. You were compliant and cooperative 
with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have 
any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The Plans denial of continued 
inpatient psychiatric services appears appropriate. 
 
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 continuation of inpatient mental health care have not been met. Therefore, 
we decided that the Plan does not have to pre-approve inpatient mental health care from April 11, 2022, 
forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of care with an out-of-network 
provider. 
 You asked the Plan to pre-approve the continuation of care. You say that care with an OON provider continues 
to be necessary. The Plan denied your request. The Plan says there are in-network providers available to 
provide comparable care. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continuation of care. Our reviewer 
says that the requested care with an OON provider is not medically reasonable and necessary. Our physician 
reviewer found the review has determined that the enrollee is a 62-year-old male with a history of paroxysmal 
atrial fibrillation on chronic Coumadin therapy. He has been receiving OON monitoring for his international 
normalized ratio (INR). There is no specific clinical rationale for OON INR monitoring. The enrollee's INR can 
be monitored within Plan. The review has determined that the documentation does not support the continuation 
of care with OON provider. 
 
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 continuation of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continuation of care with an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special corrective intraocular lenses (IOLs) placed during 
cataract surgery on October 5, 2021, and October 12, 2021, designed as astigmatism-correcting (A-C). 
 
You asked the Plan to pay for the A-C IOLs. You say that you did not get this type of lens due to astigmatism, 
but rather because you were told that this would possibly prevent the need for a vitrectomy surgery due to your 
retinal issues. You feel that this should be covered since this was done due to a medical need, and not simply to 
avoid glasses. The Plan denied your request. The Plan says this is not a type of IOL that Medicare covers for 
any reason. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the special corrective 
intraocular lenses (IOLs) placed during cataract surgery on October 5, 2021, and October 12, 2021, designed as 
astigmatism-correcting (A-C).