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

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy. 
 
You asked the Plan to pre-approve endovenous ablation therapy. 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 follows Medicare rules. Medicare rules say that endovenous ablation therapy is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve endovenous ablation therapy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not meet guideline criteria for use of this therapy. In summary, there is insufficient documentation to 
support the medical necessity for the requested endovenous ablation therapy in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement provided on April 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for nail debridement. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 nail debridement at issue in this appeal. The Plan did not pre-approve 
the nail debridement at issue. We found no exception that would require the Plan to pay for the nail 
debridement. Therefore, we decided that the Plan does not have to pay for nail debridement provided on April 
8, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
February 17, 2022, to February 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this bill should be covered. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $500 
copayment per admission.  
 
You have been asked to pay $500 copayment for inpatient hospital stay. Inpatient hospital stay falls within the 
Hospital Inpatient 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 inpatient 
hospital stay provided from February 17, 2022, to February 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37184 billed for date of service October 11, 
2021. 
 
You asked the Plan to pay for procedure code 37184. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 37184 is bundled into payment for code 34201.  
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, we have confirmed that code 37184 
is a column II code to column I code 34201. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 37184 billed for date of service October 11, 
2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve twelve additional physical therapy visits. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says these services are 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 pre-approve these services. Our reviewer says that 
the requested services are medically necessary. Our physician reviewer found that the clinical documentation 
shows that you have pain and functional impairments related to right knee osteoarthritis and your provider has 
recommended a knee replacement in regard to pain management. However, per the notes indicated and the 
evaluating therapist, you are making functional gains and further assessment/treatment is recommended. Thus, 
twelve additional physical therapy sessions are 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 been met. Therefore, we decided that the Plan has to pre-
approve twelve additional physical therapy visits.  
 
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 the office visit rendered on January 26, 2021. 
 
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 claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until March 21, 2022. A valid Waiver of 
Liability (WOL) was not received until April 22, 2022. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay 
for the office visit rendered on January 26, 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 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 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary at this time as they 
are not yet stable for transfer and as it would not be clinically advantageous. Completion of treatment at the 
current facility is recommended. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 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 SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the beneficiary does require skilled nursing 
or therapy services on a daily basis. 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglasses provided on December 22, 2021. 
 
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says the 
member must have authorization to obtain services from an out-of-network provider. 
 
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 did not pre-approve the 
eyeglasses. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on 
December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83550 billed for date of service June 1, 2021. 
 
You asked the Plan to pay for procedure code 83550. The Plan denied your request. The Plan says payment for 
code 83550 is bundled into payment for code 84466. 
 
 
 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, we have confirmed that code 83550 
is a column II code to column I code 84466. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83550 billed for date of service June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face-down recovery support rendered on November 1, 
2021, to November 8, 2021. 
 
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 provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pay for the face-down recovery 
support rendered on November 1, 2021, to November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) provided 
December 22, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this test is a proven medically necessary covered 
benefit for comprehensive genomic profile testing for cancer. The Plan denied your request. The Plan says does 
not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Genetic testing procedures submitted with code 81455 are 
unlikely to impact therapeutic decision making in the clinical management of the patient and will be denied 
automatically as not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
targeted genomic sequence analysis (81455) provided December 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service October 11, 
2021. 
 
You asked the Plan to pay for procedure code 99601. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the facet joint 
nerves. 
 
You asked the Plan to pre-approve the facet nerve RFA procedure. You say that the enrollee had good relief 
from prior injections and would benefit from the RFA. The Plan denied your request. The Plan says the 
documentation does not support that criteria are met. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint RFA treatment requires that at least 
two facet joint injections provided at least 80% pain relief.  
 
We looked at the file and Medicare rules. The documentation only shows one diagnostic facet joint injection, 
and while the record indicates the required level of pain relief, actual pain scores before and after and a 
functional ability assessment are not documented. Based on this information, we decided that Medicare rules 
for coverage of the facet nerve RFA procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a radiofrequency ablation (RFA) of the facet joint nerves.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service September 
27, 2021. 
 
You asked the Plan to pay for procedure code 99601. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service September 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
September 22, 2021. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you disagree with the Plan's 
decision. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug tests provided on May 5, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug tests. You say that the ordering physician requested the test to be 
performed and you would like the claim reprocessed for payment. The Plan denied your request. The Plan says 
the rendering and referring providers are both OON providers and there was no approved authorization. Also, 
the service rendered was not urgent or emergent. 
 
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 the drug tests provided on May 5, 2021, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services 
provided on August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from October 5, 2021, to October 
7, 2021. 
 
You asked the Plan to pay for hospital services. You say that this claim was billed correctly and should be paid. 
The Plan denied your request. The Plan says diagnosis code Z20.822 is missing a required POA indicator. This 
code is reported with a POA indicator of "1" which is the same as a blank field; however, this diagnosis code is 
not on the exempt code list. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report principal and secondary diagnoses with an appropriate POA indicator in most cases. 
 
We looked at the file and Medicare rules. Diagnosis code Z20.822 was reported with a POA indicator of 1. We 
find that this POA indicator is not supported for this diagnosis. Specifically, Z20.822 is not on the Medicare 
exemption list for 2021. This means that a POA of "1" is not appropriate for this code. Based on this information, we decided that Medicare billing rules have not been met. Therefore, we decided that the Plan 
does not have to pay for hospital services provided from October 5, 2021, to October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digitally programmable, binaural, behind the 
ear (V5253) provided February 18, 2022, from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid. You say that the Evidence of Coverage does not show that 
hearing aids can only be purchased from certain companies. The Plan denied your request. The Plan says 
hearing aids are not covered when purchased OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from a provider in the Plans hearing network. 
 
We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid, 
digitally programmable, binaural, behind the ear (V5253) provided February 18, 2022, from an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service November 
15, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service November 15, 2021.