Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services provided from June 19, 2021, 
through December 4, 2021. 
 
You asked the Plan to pay for home health aide services. You say that the home health aide services were 
medically necessary. The Plan denied your request. The Plan says the home health aide services are custodial 
and not covered. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 pay for home health aide services. Our reviewer 
says that the home health aide services were not medically necessary. Our physician reviewer found that the 
medical records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain 
your condition and/or prevent deterioration. The medical records do not show that skilled therapy services are 
required to effectively provide treatment, care, and/or services in order to improve your level of function, or to 
establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. The 
documentation does not reveal that you require skilled therapy or skilled nursing services. The services do not 
meet the definition of home health aide services per Section 50.2. The requested home health aide services are 
not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pay for home health aide services provided from June 19, 2021, through 
December 4, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you are medically stable and do not need PM&R physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. You do not require 3 hours a day five days a week of IRF therapies with interdisciplinary 
management. Your rehab needs can be provided in an alternate and low intensity setting such as in a skilled 
nursing facility or in-home services continued. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on November 23, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says refractions 
associated with non-routine vision exams are not covered under any condition. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-
covered eye condition and not a routine eye exam. Medicare does not cover refractive procedures even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on November 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient consultation services (99309) provided to the 
enrollee on October 18, 2021. 
 
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 this code is not separately payable according to incidental/mutually exclusive edits. 
 
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 99309 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has 
developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the 
bedside and on the patient's facility floor or unit.." 
 
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 in regards to the unbundled 
service, the provider reported one evaluation and management procedure code, and therefore unable to verify 
what other service was performed to confirm unbundling.  
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 inpatient consultation services (99309) provided to the enrollee on October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services from May 26, 2021 to May 27, 2021. We decided that the 
Plan does not have to pay for the services for the first midnight on 5/25/21.  
 You asked the Plan to pay for the services. You say that without taking them to the emergency room, there is 
no way you would have known it was not a heart attack. The Plan says that the services could have been 
provided at a lower level of care. 
 
We decided that the Plan has to pay for the services from May 26, 2021 to May 27, 2021.  
 
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 for the inpatient services. Our reviewer says that the 
enrollee was appropriate for conversion to inpatient status on 5/26/21 for the second midnight 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 the services have been met. Therefore, we decided that the Plan has to pay for 
the services from May 26, 2021 to May 27, 2021.  
 
We also decided that the Plan does not have to pay for the services for the first midnight on 5/25/21. 
 
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 for the inpatient services. Our reviewer says that the 
enrollee was appropriate for and intended to be on observation status for the first midnight (5/25 - 5/26). 
 
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 services for the first midnight on 5/25/21 have not been met. Therefore, we 
decided that the Plan does not have to pay for the services for the first midnight on 5/25/21. 
 
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 admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not medically reasonable and necessary. Our physician reviewer found that the 
documentation is reviewed in its entirety. The member has stabilized medically and is ready for discharge from 
the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis.  He 
is medically stable and can receive further rehab services at a lower level of care. Although further rehab 
services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing 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 admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left side facet joint radiofrequency ablation for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that the same procedure was approved and completed 
for the right side and this is a follow-up procedure for the left side. The Plan denied your request. The Plan says 
the records do not show confirmed facet joint pain. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there has not been two sets of diagnostic medial branch blocks. Therefore, this request is deemed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left side facet joint radiofrequency ablation for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for continuity of care with an out-of-network 
provider. 
 You asked the Plan to pre-approve the referral. You say that the requested procedure with the out-of-network 
provider is medically necessary. The Plan denied your request. The Plan says the enrollee can safely transition 
to an in-network provider for the requested procedure. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 referral. Our reviewer says that the 
requested referral is not medically reasonable or necessary. Our physician reviewer found the enrollee. had a 
bilobed carotid anuerysm at the carotid bifurcation. The review has determined that this enrollee does not 
currently receiving any active treatment and/or medical management of her condition that makes it medically 
necessary for this enrollee to continue care with the out-of-network Neurosurgery provider as requested. There 
is not anything unique about this enrollee's condition that would make it medically necessary for her to 
continue care with the requested out-of-network provider. The plan has shown that they have in-network 
specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care 
required for treatment of the enrollee's condition. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral for continuity of care with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 12, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says you had not 
reached your $500 deductible and you are responsible for the allowable amount of the claim, which is $97.35. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible, which applies to covered medical services. 
 
The item or service you asked the Plan to pay for falls within the benefit category of covered medical services. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible, 
which applies to covered medical services. This cost sharing is a contractual obligation that had not been met at 
the time physician's services were received on January 12, 2022. Therefore, we decided that the Plan does not 
have to pay for physician's services provided on January 12, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 29881. We decided that the Plan does not have to pay for CPT 
29876.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that this should 
not have been unbundled. 
 
We decided that the Plan has to pay for 29881.  
 
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 CPT 29881 is "Arthroscopy, knee, surgical; with 
meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular 
cartilage (chondroplasty), same or separate compartment(s), when performed."  
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 for CPT 29881. Our reviewer says that this code is 
supported in the medical records. Our physician reviewer found that per the Correct Coding Initiative (CCI) 
edits, CPT 29879 and 29891 can be billed together even if they were performed in the same compartment. 
There is no bundled relationship between CPT 29881 and CPT 29879. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
29881.  
 
We also decided that the Plan does not have to pay for 29876. 
 
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 CPT 29876 is "Arthroscopy, knee, surgical; synovectomy, 
major, 2 or more compartments (eg, medial or lateral)." 
 
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 for CPT 29876. Our reviewer says that this code is not 
supported in the medical records. Our physician reviewer found that in terms of CPT 29876, the operative 
report does not support synovectomy was performed other than for joint clean up.  Synovectomy would be 
covered separately from the more extensive procedure, when there is a pathologic synovial disease, and not for 
joint clean up.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 29876 have not been met. Therefore, we decided that the Plan does not have to 
pay for 29876. 
 
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 the StimQ Peripheral Nerve Stimulation (PNS) device 
for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is needed to treat chronic low back and 
sacroiliac joint pain. The Plan denied your request. The Plan says there are no current published studies 
evaluating this device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/investigational device. Therefore, the request is deemed 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the StimQ Peripheral Nerve Stimulation (PNS) device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystourethroscopy services provided to the enrollee on 
February 12, 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 denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 52352: 
 
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral 
catheterization is included) 
 CPT 52334: 
 
Cystourethroscopy with insertion of ureteral guide wire through kidney to establish a percutaneous 
nephrostomy, retrograde 
 
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 in terms of CPT 52352, the 
operative report describes procedures performed in the left urethra. In this case, the removal or manipulation 
would be inclusive to lithotripsy and indwelling ureteral stent, and is not support as a separate procedure. In 
terms of CPT 52334, the operative report does not describe insertion of ureteral guide wire through kidney to 
establish a percutaneous nephrostomy. Therefore this procedure cannot 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for cystourethroscopy services provided to the enrollee on February 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colonoscopy services provided to the enrollee on July 2, 
2020. 
 
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 Current Procedural Terminology (CPT) code 45380 (1 unit) remains not supported. 
 
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 45380 is "Colonoscopy, flexible; with biopsy, single or 
multiple." 
 
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 the procedure report does not include 
documentation that a single or multiple biopsy was performed, and therefore, this procedure cannot be 
verified. The procedure report documents "No specimens collected."  There would a more appropriate code to 
report for the services documented. 
 
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 colonoscopy services provided to the enrollee on July 2, 2020.