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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
household distances with a rolling walker with contact guard assistance and is contact guard assist for transfers. 
Provided records do not document a significant decline in the enrollees functional status to necessitate daily 
inpatient skilled therapy services. The enrollee does not require the services on an inpatient basis, only in a 
skilled nursing facility setting. Records do not document that services in the assisted living facility with home 
health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the limited bilateral noninvasive 
physiologic studies of the upper or lower extremity arteries (93922) provided on December 21, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment 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 a $50 
copayment for specialty physician other Medicare-covered outpatient diagnostic tests.  
 
  
You have been asked to pay a $50 copayment for the Medicare-covered outpatient diagnostic test provided by a 
specialty physician. 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 limited bilateral noninvasive 
physiologic studies of the upper or lower extremity arteries (93922) provided on December 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on December 1, 
2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you do not understand why there are 
two services you are being billed for. The Plan denied your request. The Plan says the copayment was 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 $120 
copayment for each emergency room visit when in or out-of-network.  
 
You have been asked to pay a $120 for the ER visit. The ER visit falls within the Emergency Care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ER visit provided on December 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spinal surgery services (63047, 63048) provided on January 
4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for spinal surgery services. You say that you were led to believe by representatives 
of the Plan that the services at issue would be reimbursed. The Plan denied your request. The Plan says rules 
for payment for out-of-network care have not been met. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 spinal surgery services (63047, 63048) provided 
on January 4, 2022, by an out-of-network (OON) provider.   
Your complaint about receiving erroneous or incomplete information about your out-of-network benefits from 
representatives of the Plan is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on May 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the toes (73660) provided on January 27, 2022. 
 
You asked the Plan to pay for an X-ray of the toes. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says rules for payment have not been met because the 
CPT code at issue is inclusive to another billed code. 
 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 73660 
is a column II code to column I code 73630. 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 an X-ray of the toes (73660) provided on January 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lead wires, pair (A4557) provided on November 29, 2021. 
 
You asked the Plan to pay for lead wires. You say that this claim was billed appropriately and is supported in 
the medical record. The Plan denied your request. The Plan says separate payment is never made for this 
service under the fee schedule. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT code A4557 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A4557 is not separately payable under the fee schedule. Based on this information, we decided that 
Medicare rules for coverage of lead wires have not been met. Therefore, we decided that the Plan does not have 
to pay for lead wires, pair (A4557) provided on November 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances with a front wheeled walker with stand-by assistance and is stand-by assist for transfers. 
Provided records do not document a significant decline in your functional status to necessitate further daily 
inpatient skilled therapy services. You do not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Records do not document that services in the home with home health care or in a long-
term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pelvic magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve MRI. You say that the use of MRI in planning stereotactic body radiation 
therapy (SBRT) is important in ensuring the most accurate and safest treatment is delivered. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not 
meet coverage criteria for this MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested MRI. Our physician reviewer found the enrollee 
had an MRI on February 15, 2022. It is not indicated why an additional MRI is needed at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve pelvic magnetic resonance imaging (MRI).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 20, 2021, and 
December 29, 2021. 
 
You asked the Plan to pay for psychotherapy. You say that the medical records support the medical necessity of 
the services provided and the claim should be reprocessed for payment. The Plan denied your request. The Plan 
says Licensed Professional Counselors are not able to be reimbursed by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain individuals and entities that 
frequently attempt to enroll in Medicare but are not eligible to do so. If the contractor receives an enrollment 
application from any of these individuals or entities, the contractor shall deny the application. 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, a Licensed Professional Counselor is not eligible 
for Medicare payment. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
December 20, 2021, and December 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dalvance for the enrollee. 
 
You asked the Plan to pre-approve Dalvance. You say that this is medically necessary. The Plan denied your 
request. The Plan says that it has not demonstrated that it is medically necessary to make an exception for this 
drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Dalvance. Our reviewer says that 
Dalvance is not medically reasonable and necessary. Records do not document failure of vancomycin for the 
patient's infection. There is no concern that the Dalvance would not be safe and effective for the patient, but 
records do not document failure of vancomycin for the patient's infection. Our physician reviewer found that 
the enrollee's condition does not meet criteria for coverage of Dalvance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dalvance have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Dalvance for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested 
Tertiary level of care provider. 
 
You asked the Plan to pre-approve physical therapy to be provided by the requested Tertiary level of care 
provider. The Plan denied your request. The Plan says the enrollee does not meet Tertiary level of care criteria. 
 
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 physical therapy to be provided by the 
requested Tertiary level of care provider. Our reviewer says that physical therapy to be provided by a Tertiary 
level of care provider is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of a recent injury or decline in function with regards to your symptoms. 
The physical therapy services are not necessary or appropriate to occur in a Tertiary facility 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 physical therapy to be provided by a Tertiary level of care provider have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by 
the requested Tertiary level of care provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that panels with more than 5 respiratory pathogens 
performed in the Part B outpatient setting are considered not medically necessary. 
 
We looked at the file and Medicare rules. The file shows that more than five respiratory pathogens were tested. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 22, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer for the enrollee. 
 
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your 
request. The Plan says that at least one preferred formulary drug needs to be tried and failed to meet step 
therapy criteria. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically reasonable and necessary. There is no indication that the patient has tried and failed 
Infed, Venofer or Ferrlecit. There is no indication that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition 
does not meet step therapy criteria for Injectafer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $35 copayment for each physical therapy visit provided 
October 11, 2021, to December 15, 2021. 
 
You asked the Plan to waive the $35 copayment for each physical therapy visit. You say that you did not go to 
these six (6) physical therapy visits and therefore should not have to pay the copayment. The Plan denied your 
request. The Plan says you must pay a $35 copayment for each therapy 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 clearly says that you must pay a $35 
copayment for outpatient rehabilitation services.  
 
The documentation submitted supports that you had six (6) visits on the dates of service in question. You have 
been asked to pay a $35 copayment for each physical therapy visit. Your total cost share for these services is 
$210 ($35x6).  Physical therapy visits fall 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 $35 copayment per physical therapy visit provided October 11, 2021, to 
December 15, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve continuation of physical therapy. 
 
You asked the Plan to pre-approve continuation of physical therapy. You say that additional physical therapy is 
medically necessary. The Plan denied your request. The Plan says that continued PT is 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 continuation of physical therapy. Our 
reviewer says that continued PT is medically necessary. Our physician reviewer found that the clinical 
documentation states that the enrollee is not yet stabile with her home exercise plan as different pain 
management modalities and strengthening exercises are being trialed thus, she still requires the skill of a 
professional therapist for improvement. Physical therapy is generally accepted as treatment for the diagnosis of 
low back pain and urinary incontinence and length of treatment would generally be appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of physical therapy have been met. Therefore, we decided that the 
Plan has to pre-approve continuation of physical therapy.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for UTI. 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on October 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99239 is 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 
more than 30 minutes of hospital discharge day management services spent on the enrollee. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the hospital discharge services rendered on October 9, 2021.