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

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) gastroenterologist. 
 
You asked the Plan to pre-approve an office visit. You say that these services are medically necessary The Plan 
denied your request. The Plan says the services have been requested from 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 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 to be provided by an out-of-network (OON) gastroenterologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Mohs micrographic surgery (code 17311) provided on 
September 1, 2021. 
 
You asked the Plan to pay for Mohs micrographic surgery. You say that this was a separate procedure that 
should be considered for payment. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because codes 17311 and 88305 must be reported by a single physician that performs both 
the Mohs and pathology service; furthermore, no appropriate modifier was billed to distinguish this as a 
separate service. 
 
The Plan must follow Medicare rules. Medicare rules say that a single physician must perform both the surgery 
and pathological examination of the specimen for Mohs micrographic surgery procedures.  
 We looked at the file and Medicare rules. The surgery and pathology codes were billed by different physician; 
however, a single physician must perform both services. Based on this information, we decided that Medicare 
rules for coverage of Mohs micrographic surgery have not been met. Therefore, we decided that the Plan does 
not have to pay for Mohs micrographic surgery (code 17311) provided on September 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 
24, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that the enrollee stated it was an 
emergency situation. You and the enrollee felt he needed to be treated at the hospital. The Plan denied your 
request. The Plan says the enrollee has been charged the correct copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for each Medicare-covered ground ambulance transport (one-way).  
 
The enrollee has been asked to pay a $250 copayment for ambulance transport. Ambulance transport falls 
within the Ambulance services benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for ambulance transport provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic external defibrillator (AED) garment provided 
on October 14, 2021. 
 
You asked the Plan to pay for AED garment. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this item is correct, because code K0606 was not 
billed with the required -KF modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that code K0606 must be billed with the -KF 
modifier.  
 
We looked at the file and Medicare rules. This code was not billed with the required -KF modifier. Based on 
this information, we decided that Medicare rules for coverage of AED garment have not been met. Therefore, 
we decided that the Plan does not have to pay for an automatic external defibrillator (AED) garment provided 
on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray exam of the abdomen (74018) provided on 
December 10, 2021. 
 You asked the Plan to pay for the X-ray exam of the abdomen. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says an appropriate modifier has not been billed 
with this 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 74240 
is a column II code to column I code 74018. 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 the X-ray exam of the abdomen (74018) provided on December 
10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stivarga. 
 
You asked the Plan to pre-approve Stivarga. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Stivarga.  
 
 
 Benefits for Stivarga may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 reasonable and 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 daily 
skilled services are not necessary. Our physician reviewer found 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. She 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. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on October 
27, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this was a repeat test that came 
back fine. You say you should not be charged for preventive services. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for nuclear medicine tests and procedures.  
 
The file shows that you had repeat imaging performed due to possible abnormal results from a previous test. 
For this reason, the procedure is considered diagnostic instead of preventive. Therefore, you have been asked to pay $60, which is less than the $120 copayment for the ultrasound. The ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 a breast ultrasound provided on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection (62320), provided on December 20, 2021. 
 
You asked the Plan to pay for the injection. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the records provided to the Health Plan are undated and unsigned and there is 
insufficient documentation of response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the injection (62320), provided on 
December 20, 2021. have been met. the required clinical records to support the medical necessity of the service 
for the date of service requested have not been submitted.. Therefore, we decided that the Plan does not have to 
pay for the injection (62320), provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 
10, 2022. 
 
You asked the Plan to waive the copayment for the office visit. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $48 
copayment for specialist services from a specialist other than a level 1 specialist.  
 
You have been asked to pay a $48 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist office visit provided on January 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
May 26, 2021. 
 
You asked the Plan to pay for hospital discharge management. You say that this service was billed 
appropriately. The Plan denied your request. The Plan says this service is not supported as billed. 
 
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, the time spent providing this 
service is not noted in the medical record. Based on this information, we decided that Medicare rules for 
coverage of hospital discharge management have not been met. 
 
 
  Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99239) 
provided on May 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right reverse total shoulder arthroplasty (23472). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says there is no evidence on 
physical exam or advanced imaging that you have a torn or deficient rotator cuff. Therefore, the policy criteria 
has 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 the surgical 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 documentation of irreparable rotator cuff tear. A reverse shoulder 
procedure is not medically needed and the criteria has not been met. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve right reverse total shoulder arthroplasty (23472).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lingual frenulectomy. 
 
You asked the Plan to pre-approve tongue surgery services. You say that this surgery is medically reasonable 
and necessary. The Plan denied your request. The Plan says the criteria for coverage 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 tongue surgery services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that according to the American Academy of Otolaryngology-Head and Neck Surgery 
(AAO-HNS) clinical consensus statement on ankyloglossia, the review panel reached consensus on the 
statement that ankyloglossia is a condition of limited tongue mobility caused by a restrictive lingual 
frenulum. The AAO-HNS statement concluded that indications for frenulum surgery may include some 
infants with breastfeeding difficulty and some mothers with breast or nipple pain during breastfeeding. The 
AAO-HNS panel on ankyloglossia also noted that frenulum surgery is an option for older children with 
speech articulation and/or other mechanical social issues, but the evidence is limited and of relatively poor 
quality.   
In this case, there was no clinical documentation that the patient had ankyloglossia; the oral exam reported 
tongue midline, no oropharyngeal edema, tonsils WNL. There was also no documentation of speech or 
swallowing difficulties; the history of present illness from the note dated April 11 noted that the patient denied 
dysphagia and odynophagia. Overall, there is no clinical documentation that the patient had ankyloglossia, or 
speech and swallowing difficulties that might have been attributable to ankyloglossia. In summary, lingual 
frenulectomy is not medically reasonable and necessary 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 tongue surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lingual frenulectomy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee cannot care for herself at home. The 
Plan denied your request. The Plan says the enrollee does not need skilled nursing or therapy services. 
 
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 physician reviewer 
found that the enrollee presented to the acute hospital with severe anemia, a sacral wound with suspicion for 
necrotizing fasciitis and sepsis, a pleural effusion with respiratory failure, Clostridium Difficile colitis and a 
cerebral hemorrhage. The records do not document the need for intravenous medications, new tube feeding, or 
ostomy care or daily complex wound care. She is weak and deconditioned. She is non-ambulatory and is at a 
maximum/total assist for transfers. Although records document she is very limited functionally, the provided 
records do not document a significant decline in her functional status compared to her recent baseline to 
necessitate daily inpatient skilled therapy services. There is no documentation that the patient requires the 
services on an inpatient basis, only 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 skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on October 6, 
2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that the lab tests were for a pre-op 
visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for lab services provided at an outpatient hospital facility.  
 
You have been asked to pay $18.98, which is less than the $50 copayment for the lab services. The lab services 
fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory services provided on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that this item is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says these items are not covered by Medicare 
or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for SNF care and can be treated at a lower level 
of care such as at home health with home health services or in residential care with a close follow-up with her 
doctor. 
 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 that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital emergency services 
provided on January 31, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital emergency services. You say that the 
enrollee was admitted and transferred to another hospital so the emergency room copayment should not be 
applied. The Plan denied your request. The Plan says then enrollee was admitted to a different provider for 
inpatient stay. Therefore, the proper copayment for the emergency room services was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for Emergency Room Emergency Services.  
 
  The enrollee has been asked to pay a $90 copayment for the outpatient hospital emergency services. The 
outpatient hospital emergency services falls within the Outpatient hospital services benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for the outpatient hospital emergency services provided on 
January 31, 2022.