Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need at least 3 hours a day of therapy to make 
measurable improvement with 24 hours of nursing supervision. The Plan denied your request. The Plan says 
the records do not show that the enrollee requires rehabilitation nursing care 24 hours a day and that they need 
at least 3 doctor visits per week. The records also show that the enrollee does not need daily nursing care. The 
enrollee's current needs can be met at home with home 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 the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. The enrollee does not need 3 hours a day or 5 days a week of therapies. 
 
Documentation does not support the medical necessity due to lack of medical complexity and nursing needs for 
admission to an IRF. While the enrollee would benefit from physical therapy and occupational therapy the 
enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as an 
outpatient facility. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $45 copayment for an urgent care visit on November 21, 
2021.  
 
You asked the Plan to waive the $45 copayment for an urgent care visit. You say that the reason for this visit 
was because you were exposed to COVID, therefore you should not be responsible to pay this copayment. The 
Plan denied your request. The Plan says the copayment has been applied 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 a $45 
copayment for urgent care visit.  
 
You have been asked to pay a $45 copayment for an urgent care visit. An urgent care visit falls within the 
Urgently Needed Services 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 $45 copayment for an 
urgent care visit on November 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 copayment for physical therapy provided on January 
31, 2022. 
 
You asked the Plan to waive the $40 copayment for physical therapy. You say that you are unable to pay this 
amount. The Plan denied your request. The Plan says the copayment has been applied 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 a $40 
copayment for physical therapy.  
 
You have been asked to pay a $40 copayment for physical therapy. Physical therapy falls within the Outpatient 
Rehabilitation Services 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 $40 copayment for 
physical therapy provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device, four or more leads, for multiple nerve stimulation (E0730) and electrical stimulator supplies, 2 lead, per 
month (A4595) provided on March 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the TENS device and supplies. You say that the claim denied in error. The 
primary diagnosis M54.59 (other low back pain) is a valid and payable diagnosis for procedure code E0730. 
The Plan denied your request. The Plan says a tens unit and garments and supplies for chronic back pain is not 
a Medicare covered benefit. 
 
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 at issue in this case is not a network provider with the Plan. 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 TENS device and supplies. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has chronic low back pain and was prescribed a TENS unit. The enrollee is not enrolled in a 
CMS clinical trial of TENS. The NCD criteria preclude the use of TENS for the therapy of low back pain. The 
device, therefore, was not medically reasonable or 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 the TENS device and supplies have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for the TENS device and supplies. Therefore, we decided that 
the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) device, four or more 
leads, for multiple nerve stimulation (E0730) and electrical stimulator supplies, 2 lead, per month (A4595) 
provided on March 1, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a right total/reverse shoulder arthroplasty. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 services are medically necessary. Our physician reviewer found the enrollee you are being treated for 
chronic right shoulder pain, osteoarthritis of the right glenohumeral joint, and a history of right rotator cuff 
repair. You have been treated conservatively for right shoulder glenohumeral osteoarthritis. The exam of the 
right shoulder reveals tenderness. There is significant crepitus (grating sound/sensation) on passive motion. The 
provided documentation demonstrates subjective and objective deficits that are corroborated by imaging 
studies. You have tried and failed reasonable conservative treatment. Therefore, this requested right 
total/reverse shoulder arthroplasty is 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a right total/reverse shoulder arthroplasty.  
 
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 make additional payment for the outpatient hospital care provided 
from October 8, 2021, through October 9, 2021. 
 
You asked the Plan to make additional payment for the outpatient hospital care. You say that the primary 
insurer's maximum benefit was exhausted. Additional payment should be made by the secondary payer. The Plan denied your request. The Plan says the primary insurer has paid more than the gross amount payable by 
Medicare. As such, no further payments are due. 
 
The Plan must follow Medicare rules. Medicare rules say that for services such as outpatient hospital care, 
which are reimbursed under a prospective payment system, the lowest of the four calculations listed in the 
Medicare rules section of this decision determine the amount payable.   
 
We looked at the file and Medicare rules. In this case, the amount for calculation number 2 is negative, as the 
primary paid more than the gross amount payable by Medicare. Since this is less than zero, there is no 
secondary payment due. Based on this information, we decided that Medicare rules for coverage of the 
outpatient hospital care have not been met. Therefore, we decided that the Plan does not have to make 
additional payment for the outpatient hospital care provided from October 8, 2021, through October 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 26, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81328, 81335, 81355, 
81407, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 26, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 
81306, 81328, 81335, 81355, 81407, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider from January 27, 2022, through January 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider from January 27, 2022, through January 31, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met.  
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary 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 an epidural steroid injection. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the request meets the 
criteria for an epidural steroid injection. The procedure is 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 been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the request for Intracept intraosseous 
basivertebral nerve ablation at L4-5 is not medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. More research is needed to show safety and 
efficacy when used as bone graft material. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 12, 2021, billed 
with codes 81238, 81220, 81226, 81225, 81335, 81227, 81230, 81355, 81241, 81291 and 81240. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 12, 2021, billed with codes 81238, 81220, 81226, 81225, 81335, 81227, 81230, 81355, 81241, 
81291 and 81240.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 13, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says with the 
information we have, we cannot determine how the member came to the servicing provider, or whether the 
services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physicians intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that 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 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 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 your nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional therapy is necessary to allow 
the enrollee to safely navigate 22 stairs to enter their home. The Plan denied your request. The Plan says the 
enrollee has reached their maximum potential. The Plan also says the additional PT visits 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that you or your caregivers should be independent with a home 
exercise program. The reviewer found that the provided documentation does not indicate a recent injury or 
further decline in function. Therefore, the reviewer found that additional therapy services are not an appropriate 
duration and frequency for treatment of your medical condition and therefore are 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 20 additional physical therapy (PT) visits.