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

 
We decided that the Plan does not have to pay for procedure codes 77003 and J3490 billed for date of service 
September 27, 2022. 
 You asked the Plan to pay for the services. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says the services were not reported correctly. 
 
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 77003 is a column II code to column I code 64490. This claim has 
not been billed with an appropriate modifier to bypass the edit. 
 
Additionally, in terms of J3490, this should not be reported separately within the zero day global period of CPT 
64490. 
 
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 codes 77003 and J3490 billed for date of service September 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 15, 2022 
to October 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the home health services were 
medically necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 15, 2022 to 
October 7, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the telemedicine visit. We decided that the Plan 
does not have to waive the copayment for the office visits.  
 
You asked the Plan to waive the copayment for the five specialist office visits and the one specialist 
telemedicine visit provided from September 19, 2022, to November 18, 2022. You say that you would like the 
cost sharing for these services to be lower. The Plan says that this cost sharing was charged correctly. 
 
 We decided that the Plan has to reduce the copayment for the telemedicine visit.  
 
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 says that you must pay a $30 
copayment for each telehealth specialist visit. The Plan says you must pay a $35 copayment for the specialist 
telemedicine visit. Based on the Plan contract however, you cannot be asked to pay more than $30 for the 
specialist telemedicine visit. Therefore, we decided that the Plan has to reduce the copayment for the 
telemedicine visit.  
 
We also decided that the Plan does not have to waive the copayment for the office visits. 
 
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 $35 
copayment for each in-person specialist visit. 
 
The specialist telemedicine visit and the specialist office visits fall within the physician/practitioner services, 
including doctors office visits benefit category. Based on your contract with the Plan, this means that you are 
responsible for a $205 copayment for the telemedicine visit and the office visits ($35 x 5 office visits = $175) 
($175 + $30 telemedicine visit = $205). 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 the five 
specialist office visits and the one specialist telemedicine visit provided from September 19, 2022, to 
November 18, 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: 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 enrollee needs continued services in the skilled 
nursing facility to help reach maximum function. The Plan denied your request. The Plan says the enrollee does 
not meet the guidelines and no longer requires skilled services on a daily inpatient basis and the continuation of 
SNF 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 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 enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0127 billed for date of service October 25, 
2022. 
 You asked the Plan to pay for the billed services. You say that the code is covered when modifier 59 is added. 
The Plan denied your request. The Plan says the anatomic location was not specified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code G0127 is trimming of dystrophic nails, any number. We 
find that CPT code G0127 was performed on nails of the left and right foot. The code was not billed with a 
modifier indicating the location of the procedure. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0127 billed for date of service October 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 16, 2022 to June 
20, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with an appropriate "G" code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the home health services have been 
met. No medical records were provided for review. Without this information it cannot be determined if the 
claim was billed with an appropriate G code. Therefore, we decided that the Plan does not have to pay for 
home health services provided on January 16, 2022 to June 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autologous platelet rich coagulant placement (20999). 
 
You asked the Plan to pay for the autologous platelet rich coagulant placement. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the autologous platelet rich coagulant 
placement. Our reviewer says that the requested service is not considered medically reasonable and necessary 
in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed 
literature that shows platelet-rich plasma (PRP) injections to be an effective and/or safe treatment for hip 
pathology. Further/ongoing testing/studies are needed to corroborate that platelet-rich plasma provides 
significant improvement outcomes for hip pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 autologous platelet rich coagulant placement have not been met. Therefore, 
we decided that the Plan does not have to pay for the autologous platelet rich coagulant placement (20999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77370 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 77370. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 77370 is bundled into payment for code 77301. 
 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 77370 
is a column II code to column I code 77301. 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 77370 billed for date of service October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs aggressive rehab to 
return to their prior level of independency. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, and the enrollee can safely receive the care they need in the current hospital setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The plan has approved ongoing care in the current 
acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on July 12, 2022. 
 
You asked the Plan to pay for the physician services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says you received these services from a provider who 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 pay for the 
physician services provided on July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (74230, 74240) provided on October 6, 
2022 
 
You asked the Plan to pay for the radiology services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Procedures and examinations which are not 
covered under the portable x-ray provision include the following: Procedures involving the use of contrast media. 
 
We looked at the file and Medicare rules. These procedures were performed in the mobile setting and included 
use of a contrast media. Based on this information, we decided that Medicare rules for coverage of the 
radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology 
services (74230, 74240) provided on October 6, 2022
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 2, 2022 to August 
31, 2022. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the home health services are not supported in the record. Specifically, the claim has been billed for 
a 30 day episode of care, however the patient discharge status code is submitted as 06. This indicates the 
patient was discharged before the full 30 days. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided on August 2, 2022 to August 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for methadone treatment provided on October 03, 2022. 
 
You asked the Plan to pay for methadone treatment. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for methadone treatment 
provided on October 03, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's medical needs are too 
complex for a lower level of care. You say that the enrollee requires extensive rehabilitative therapies to help 
regain their strength. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee can receive the care they need in the current hospital setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The plan has approved ongoing care in the current 
acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 wants to continue doing physical and 
occupational therapy. The Plan denied your request. The Plan says the records received do not support the 
enrollee's therapy needs are complex and require an intensive inpatient therapy program with multiple visits 
from a rehabilitation doctor. 
 
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 clinical documentation does not specify any active medical comorbidities or complex 
functional impairments thus the complexity of the enrollee's documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that Gemtesa is medically necessary and reasonable for 
the enrollee's medical condition. The Plan denied your request. The Plan says Medicare Part B is not 
responsible for this drug. 
 
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 Gemtesa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that your doctor does not understand why you 
were denied the SSBCI benefits. The Plan denied your request. The Plan says based on the information 
submitted, there is no documentation that the enrollee meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
 
  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 SSBCI benefits. Our reviewer says that 
you do not meet the coverage criteria for SSBCI benefits. Our physician reviewer found you have a medical 
history significant for obesity, Hypertension (HTN), Dyslipidemia, Diabetes Mellitus II, Gastroesophageal 
reflux disease (GERD), seasonable allergies, and history of back surgery. The recent notes describe regular 
checkups with the treating physician as well as a few visits for acute conditions such as viral infections. Our 
reviewer also found that there was no clear documentation that describes you have a chronic condition that 
would meet the criteria for coverage for SSBCI benefits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do 
not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan 
does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).