Persius/hicric huggingface dataset:
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 it is medically necessary for the enrollee to facilitate 
increased independence and return home with improved quality of life. The Plan denied your request. The Plan 
says the IRF services you are requesting do not meet the requirements for approval. 
 
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 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's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires or can tolerate this therapy on an intensive IRF level. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit (99205) and osteopathic 
manipulative treatment (98929) provided on August 2, 2022. 
 
You asked the Plan to reimburse you for the physician services. You say that you do not understand why you 
pay extra for out-of-network coverage if it is not covered. You say that you have coverage. You say that the 
provider does not accept any insurance. You also say that the in-network provider did not help with your Lyme 
issue at all. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. 
The Plan says that payment cannot be made for services performed by a provider that has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.  
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the office visit (99205) and osteopathic manipulative treatment (98929) provided on August 2, 2022.
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 requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the medical record is reviewed in its entirety. The member has stabilized medically 
and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The member has 
tolerated inpatient rehab services and continues to improve with daily skilled nursing and/or skilled therapy 
services. She could benefit from continued services at the current level of care. The member has made slow 
progress with therapy, there is no indication that transfer to a skilled nursing facility is required. She can 
continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care when 
appropriate. There are no services offered at a SNF that are not offered at an inpatient rehab facility.  
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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Monovisc injection. 
 
You asked the Plan to pre-approve a Monovisc injection. 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 a repeat series* of hyaluronan knee injection(s) for 
patients who have responded to a prior series is considered to be reasonable and necessary under certain 
circumstances. 
 
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 Monovisc injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the medical 
records submitted do not discuss or disclose any kinds effects the first injections had on the members pain 
levels, activities, or decrease in oral medications. There is no information that states the enrollee has still been 
having pain since the injections in May, 2022. He was referred to physical therapy, but it is unclear if it was 
completed. The review has determined that the enrollee does not meet the coverage criteria detailed in 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 Monovisc injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Monovisc injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided on June 12, 2022. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that this should be covered. The 
Plan denied your request. The Plan says there is no evidence to support the ordering provider ordered this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. The record shows that the Plan contacted the enrollee's 
physician's office and confirmed that there was no order made for this item. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) provided on June 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and brief emotional/behavioral 
assessment (96127) provided on May 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan also says that the services 
were not urgent or emergent in nature. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.    
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Specifically, the file shows that the enrollee presented to 
the out of area providers office to establish care and thus the services are not urgent or emergent. Therefore, 
we decided that the Plan does not have to pay for the office visit (99204) and brief emotional/behavioral 
assessment (96127) provided on May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for advanced imaging services provided on 
March 16, 2022, to July 19, 2022. 
 
You asked the Plan to waive the copayment for advanced imaging services. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $180 
copayment for outpatient diagnostic tests and therapeutic services and supplies. There were three advanced 
imaging services, resulting in a total copayment amount of $540. 
 
You have been asked to pay $180 copayment for each advanced imaging service. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies 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 advanced imaging services provided on March 16, 2022, to July 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for advanced imaging service provided on May 
31, 2022. 
 
You asked the Plan to waive the copayment for advanced imaging service. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $180 
copayment for inpatient stay: covered services received in a hospital or SNF during a non-covered inpatient 
stay.  
 
You have been asked to pay $97.29 which is less than the $180 copayment for advanced imaging service. This 
item/service falls within the inpatient stay: covered services received in a hospital or SNF during a non-covered 
inpatient stay 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 advanced imaging service 
provided on May 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical knee arthroscopy (procedure code 29867) provided 
to the enrollee on June 17, 2022. 
 
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 29867 is "Arthroscopy, knee, surgical; osteochondral 
allograft (eg, mosaicplasty)." 
 
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 the records do not support that 
CPT 29867: arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty) was rendered in this 
case. The procedure details cite that cartilage grafting was then begun. Arthrex Biocartilage matrix was used 
which was mixed with autograft and also platelet-rich plasma to fill the medial femoral condyle defect site. The Arthrex Biocartilage is an extracellular matrix and not an osteochondral allograft. 
 
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 a surgical knee arthroscopy (procedure code 29867) provided to the enrollee on June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the requested ESI. You say that the injection is necessary for the enrollee. 
The Plan denied your request. The Plan says there is not sufficient documentation of the duration of pain relief 
from prior ESIs. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESIs are covered when prior treatments 
produced at least 50% pain relief lasting at least 3 months.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested ESI. Our reviewer says 
that the requested ESI is not medically necessary. Our physician reviewer found there is no documentation of at 
least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline for 
at least three (3) months with the enrollee's prior lumbar epidural steroid injections on 06/29/2021 and in 
October 2021. The review has determined that the coverage criteria have 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 requested ESI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an epidural steroid injection (ESI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is very motivated to get back to his prior 
level of function so that he can care for his son. The Plan denied your request. The Plan says the services 
needed can be provided safely 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 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 the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not require intensive physician and nursing oversight in an IRF. While the patient may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the patient requires this therapy on an intensive IRF level. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the patient lift rendered on June 25, 2022. 
 
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 diagnosis is not supported. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with mismatched 
diagnosis codes. 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 patient lift rendered on June 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a power wheelchair (E1012, E2377, K0861, E1007) provided on July 
20, 2022. 
 
You asked the Plan to pay for the power wheelchair. You say that this item was medically necessary. The Plan 
denied your request. The Plan says that the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan's denial did not fully articulate the reason for the denial. The plan did 
not cite the rules or regulations used to make the determination. Therefore, we decided that the Plan has to pay 
for a power wheelchair (E1012, E2377, K0861, E1007) provided on July 20, 2022.  
 
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 pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested injection does not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that 
this 70-year-old gentleman has bilateral lower extremities weakness. The enrollee has tried physical therapy, 
home exercise and chiropractic treatment. The enrollees magnetic resonance imaging shows a disc bulge at 
L4-L5 and spondylolisthesis of L5-S1. The enrollee does not have an indication for an epidural steroid 
injection. The request is not medically reasonable and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services denied with status codes G, K 
and H and provided on August 12, 2021, through October 7, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. 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 
support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge--sometimes 
referred to as the "room and board" charge. 
 
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 inpatient hospital services. Our reviewer says that the 
documentation submitted does not support the items and services which were denied with status codes G and 
K.  These charges are routine and would be included in the payment for hospital stay. Our reviewer found the 
documentation does not support the items and service which were denied with status code H. The claims report 
this service was credited on August 13, 2021, which resulted in a duplicate claim;  
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital services denied with status codes G, K and H and provided 
on August 12, 2021, through October 7, 2021.