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

 
We decided that the Plan does not have to pay for the angiography (75710), aortography (75625) and selective 
catheter placement (36247) provided from June 16, 2021, through June 18, 2021. 
 
You asked the Plan to pay for the angiography (75710), aortography (75625) and selective catheter placement 
(36247). You say that the operative report documents the procedures separately. You say that the services 
rendered were medically necessary and should be fully reimbursed. The Plan denied your request. The Plan 
says procedure code 75710 is considered inclusive to CPT code 37211. The Plan also says that CPT codes 
75625 and 36247 are not supported in the medical records. 
 
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 75710 is angiography, extremity, unilateral, radiological 
supervision and interpretation. The CPT Code Manual definition of code 75625 is aortography, abdominal, by 
serialography, radiological supervision and interpretation. The CPT Code Manual definition of code 36247 is 
selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower 
extremity artery branch, within a vascular family. 
 
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 angiography (75710), aortography (75625) and selective 
catheter placement (36247). Our reviewer says that the documentation submitted was reviewed and does not 
meet the criteria for coverage. Our reviewer found that for CPT code 75710-59, the procedure report does not 
include documentation of a separate procedure from the arterial infusion and there was no catheter movement 
from this procedure to support a separate procedure. Our reviewer says that the procedure report does not 
include documentation of an aortography abdominal serialography or documentation of selective catheter 
placement. Therefore, CPT codes 75625 and 36247 could not 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 angiography (75710), aortography (75625) and selective catheter placement 
(36247) have not been met. Therefore, we decided that the Plan does not have to pay for the angiography 
(75710), aortography (75625) and selective catheter placement (36247) provided from June 16, 2021, through 
June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the treatment of a bladder lesion (51720) 
provided from August 10, 2021, through September 14, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $50 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office.  You have been asked to pay $300 ($50 copayment x 6) for the treatments provided in a specialists office. 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 copayments for the treatment of a bladder lesion (51720) provided from 
August 10, 2021, through September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost share for the office visit (99204) provided on  
October 4, 2021. 
 
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
service provided. 
 
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 50% of 
the total allowed amount, per provider per day for each out-of-network Medicare-covered primary care 
provider and specialist office visit.  
 
You have been asked to pay $81.21 (Plan allowed amount of $162.42 x 50% coinsurance) for the office visit 
rendered by an out-of-network provider. 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 adjust the cost share for the office visit (99204) provided on October 4, 
2021.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 patient appears to be more stable and gradually improving but requires only 
short-term additional acute care services to further stabilize and wean off the ventilator that can safely be 
administered at the current facility for the time being. The patient does not require services at the LTACH that 
are not already available at the current facility. There are no services at the LTACH that the patient requires 
that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary 
as it would not be clinically advantageous at this time. Transfer to a lower level of care may be considered 
when treatment is 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from March 10, 
2021, to March 15, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the DRG was updated. 
 
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 177 (RESPIRATORY INFECTIONS AND 
INFLAMMATIONS WITH MCC). The plan updated the DRG to DRG 178 (RESPIRATORY INFECTIONS 
AND INFLAMMATIONS WITH CC).. 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 the enrollee is a 53-year-old woman with a history of heart disease, chronic 
obstructive pulmonary disease, diabetes, hypertension, and morbid obesity, who was admitted to the hospital 
on 3/10/21 with fever and pneumonia. The impression includes "#transient acute hypoxic respiratory failure - 
requiring NC 4Lmin in ED - much improved now". The limited available documentation supports DRG 177, 
with documentation of acute respiratory failure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided to the enrollee from March 10, 2021, to March 15, 2021.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee is having breathing 
problems. The Plan denied your request. The Plan says that an inpatient hospital stay is not necessary; 
however, this might be an observation stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record shows that at the time of inpatient admission the 
admitting physician reasonably expects that the enrollee's necessary hospital care (including earlier emergency 
department (ED) and/or observation care) will span two (2) midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 you are not receiving therapy and need more care to 
be at baseline. You state you are currently bed bound and have no help at home. You state you are unable to 
walk and have no upper body strength. The Plan denied your request. The Plan says the stay is not medically 
necessary based on IRF criteria. The Plan states you can safely receive the services you need in other settings, 
for example: a skilled nursing facility. 
 
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 there is insufficient documentation to demonstrate that the complexity of your 
nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The documentation does not support that you require at least three (3) hours a 
day, five (5) days a week, or fifteen (15) hours over seven (7) consecutive days, of therapy services. It is not 
clear that you 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that the enrollee is a suitable candidate 
for a Spinal Simplicity interspinous spacer device secondary to degenerative disc disease, fluid in the facet 
joints, and spinal stenosis pain at the L3-L4 and L4-L5 levels. You say that an x-ray of the lumbar spine shows 
that the enrollee has severe degenerative disc disease and neural foraminal narrowing along with spinal stenosis 
at the L3-L4 and the L4-L5 along with the L5-S1 level. The enrollee also has some scoliosis to the left and 
lumbar facet arthropathy from L2 to S1. The Plan denied your request. The Plan says the requested treatment is 
unproven and not medically necessary due to insufficient evidence of efficacy. 
 
  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 pre-approve the Minuteman procedure. Our 
reviewer says that the Minuteman procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this requested procedure is experimental. More research is needed to show safety 
and efficacy. 
 
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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
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 intense physical therapy would greatly benefit the 
enrollee far greater than skilled nursing if performed as soon as possible for the greatest benefit. The Plan 
denied your request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's 
ongoing skilled therapy and nursing needs can be provided at a lower level of care 
 
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 based on the documentation provided, the enrollee does not require the 
intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per 
week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states home 
physical therapy or physical therapy at a skilled nursing facility may be covered if requested. 
 
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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that the enrollee requires at least three (3) hours a day, 
five (5) days a week, or fifteen (15) hours over seven (7) consecutive days, of therapy services. It is not clear 
that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Therapy services may be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on September 16, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You sent in the referral. The Plan denied your request. 
The Plan says no prior authorization was obtained. 
 
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 
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 pathology services provided on September 16, 
2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
by a network facility from September 3, 2021, to September 30, 2021. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you were made to stay at the facility 
longer than needed in order for the facility to make money. The Plan denied your request. The Plan says you 
have been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for each day for days 1 to 20 and a $184 copayment each day for days 21 to 57.  
 
 You have been asked to pay a $1,288 copayment for the SNF care. The SNF care falls within the Skilled 
Nursing Facility (SNF) Care benefit category. See chart below. 
 
Dates of Service Service SNF Days Copayment Day Count Member 
Liability 
September 3, 2021, to 
September 22, 2021 
SNF care 1-20 $0 20 $0 
September 23, 2021, 
to September 30, 2021 
SNF care 21-28 $184 7 $1,288 
Total     $1,288 
 
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 skilled nursing facility (SNF) care provided by a network 
facility from September 3, 2021, to September 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation services 
(A0427, A0425) provided on July 25, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are on a limited 
income and cannot afford this bill. The Plan denied your request. The Plan says this claim was processed 
correctly, and your copayment was assessed in accordance with your contract. Ambulance services require a 
$325 copayment per trip. 
 
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 $325 
copayment for ambulance services.  
 
 You have been asked to pay a $325 copayment for the ambulance services. 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 the ambulance transportation services (A0427, A0425) provided on July 25, 2020.