Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a specialist (99204) to be provided 
by an out-of-network (OON) provider in Durham, North Carolina. 
 
You asked the Plan to pre-approve an office visit with a specialist. You say that the enrollee has an extensive 
support system in Durham NC, including his brother who is an oncologist on staff at Duke. This kind of 
support would not be available to the enrollee if he were in Jacksonville or Gainesville, Florida. The Plan 
denied your request. The Plan says you must use network providers to get your medical care and services. The 
Plan also says the enrollee's needs can be met by in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with a specialist (99204) to be provided by an out-of-network (OON) provider in Durham, North 
Carolina.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services codes 29876 and 29881 provided on 
March 10, 2022. 
 
You asked the Plan to pay for the surgery services as billed. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says no separate payment is due for these 
codes. 
 
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 29876 is  Arthroscopy, knee, surgical; synovectomy, 
major, 2 or more compartments (eg, medial or lateral) and the CPT Code Manual definition of code 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 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 surgery services as billed. Our reviewer says that the 
documentation does not support payment for the services as billed. Our reviewer found proper billing practices were not followed as the modifiers attached were not correct. Per correct coding edits, Modifier 51 should be 
appended to the additional procedure codes in this case. 
 
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 surgery services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgery services codes 29876 and 29881 provided on March 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrophysiologic study with 3-D mapping and 
procedure to scar tissue in the heart to block irregular electrical signals (ablation) as well as all associated codes 
requested including evaluation of a pacing cardioverter-defibrillator (93613, 93642, 93653, 93654). 
 
You asked the Plan to pre-approve outpatient procedures. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the requested services you and/or your provider is/are 
requesting do not meet the requirements for approval. 
 
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 outpatient procedures. 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 evidence of syncope or any significant supraventricular or ventricular 
arrhythmias. In summary, there is insufficient documentation to support the medical necessity for 
electrophysiologic study with 3D mapping, supraventricular arrhythmia evaluation and ablation, ventricular 
arrhythmia evaluation and ablation in this enrollees clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electrophysiologic study with 3-D mapping and procedure to scar tissue in the 
heart to block irregular electrical signals (ablation) as well as all associated codes requested including 
evaluation of a pacing cardioverter-defibrillator (93613, 93642, 93653, 93654).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 210 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need these rides to reach 
medical appointments. The Plan denied your request. The Plan says there is no benefit for routine 
transportation after 30 one-way rides are exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan statutorily does not provide coverage for routine transportation after the 30 one-way trip benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pre-approve 210 additional routine 
transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for further costs relating to the supplemental over-the-counter 
(OTC) benefit offered by the Plan. 
 
You asked the Plan to pay for the OTC supplemental benefit. You say that you had not exhausted your benefit 
at the time services were rendered. The Plan denied your request. The Plan says the benefit had been exhausted 
and no further payment is due relating to this supplemental benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
supplemental benefit is an OTC item. However, the Plan offers supplemental coverage for OTC items. The 
Plan provided $60 quarterly for eligible OTC items. 
 
In this case, the Plan confirmed that you have used your $60 supplemental benefit for the first quarter of 2022. 
The Plan has indicated you used $38.48 on February 20, $5.69 on February 26, and $15.83 on March 31. The 
record shows that the $60 quarterly benefit was exhausted. Therefore, we decided that the Plan does not have to 
pay for further costs relating to the supplemental over-the-counter (OTC) benefit offered by the Plan.
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 SNF care is medically necessary for the enrollee's 
condition. 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 based on the 
documentation provided, it is my opinion that the enrollee does not qualify for SNF coverage.  The enrollee 
does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs.  
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, 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 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 extracapsular cataract removal with insertion of 
intraocular lens prosthesis (66984) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve cataract surgery. You say that your surgery needs to be done in a surgery 
center that is equipped to manage your medical needs. The Plan denied your request. The Plan says there are 71 
in-network facilities within a 50-mile radius of your zip code. The Plan also says you must receive your care 
from a 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) to be provided by an out-of-
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for SNF care and can be treated in a lower level of care. 
 
  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 services. Our reviewer says that 
the enrollee does not meet the criteria for SNF admission. Our physician reviewer found there are no 
identifiable skilled nursing service needs. Although there are identifiable skilled therapy service needs, the 
enrollee does not require skilled nursing or therapy services on a daily basis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for SNF care and can be treated in a lower level of care. 
  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 services. Our reviewer says that 
the enrollee does not meet the criteria for SNF admission. Our physician reviewer found there are no 
identifiable skilled nursing or skilled therapy service needs. The enrollee does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that you are appealing the 
denial of the 10 additional outpatient therapy sessions. The Plan denied your request. The Plan says additional 
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 10 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had prior therapy 
and instruction in a home exercise program. The documentation does support the enrollee requires the unique 
skills of a professional therapist to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is stable and suitable for admission to an 
IRF. You say that skilled nursing is not an appropriate safe level of care at this time, as the enrollee will need 
more frequent physician visits and frequent monitoring and interventions. You say that the enrollee requires 
aggressive therapy and close physician monitoring. The Plan denied your request. The Plan says the guidelines 
for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another 
setting. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery for a compression fracture. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. 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 this enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that you have orthopedic surgery on 8/25/22 and 
you will need the shower chair. Without the assistance of a shower chair, you cannot stand in the shower. The 
Plan denied your request. The Plan says the item requested is not covered by Medicare or the Plan, it is 
considered a convenience item and not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee's family is unable to care for them at 
the current level of care. The Plan denied your request. The Plan says the enrollee's needs can be provided at an 
alternate level of care. 
  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 services. Our reviewer says that 
SNF services are not medically necessary. Our physician reviewer found there are no identifiable skilled 
nursing service needs. Although there are identifiable skilled therapy service needs, the enrollee does not 
require skilled nursing or therapy services on a daily basis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram provided on July 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the mammogram. You say that it was assumed prior authorization was not 
needed because this was a screening mammogram. 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 
mammogram. We found no exception that would require the Plan to pay for the mammogram. The records 
provided for review do not show that the mammogram was urgent or emergent. Therefore, we decided that the 
Plan does not have to pay for the mammogram provided on July 23, 2021, by an out-of-network (OON) 
provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI) 
services. 
 
You asked the Plan to pre-approve SSBCI services. You say that these services are necessary for your 
condition. The Plan denied your request. The Plan says that your provider has attested that you do not qualify 
for these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied coverage for these services stating that your 
provider attested that the services were not ready. This attestation was not included in the case file. We 
requested a copy of the attestation or medical records from the provider indicating if the services meet the 
criteria for coverage. A response to our request was not returned. Therefore, we decided that the Plan has to 
pre-approve special supplemental benefits for the chronically ill (SSBCI) services.  
 
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.