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

 
We decided that the Plan does not have to pre-approve the microsurgical techniques (69990). 
 
You asked the Plan to pre-approve the microsurgical techniques. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says CPT code 69990 is 
bundled into the payment for the primary procedure. 
 
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 microsurgical techniques. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the member is having lumbar fusion surgery with allograft and screws for 
spondylolisthesis. The use of a microscope is not absolutely medically needed and if it is it should be covered 
with the fusion and ecompression surgical codes with the included bundle. It should not be approved 
separately. 
 
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 microsurgical techniques have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the microsurgical techniques (69990).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on February 2, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the physician services provided on February 2, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a grab bar purchased on March 19, 2021. 
 
You asked the Plan to pay for a grab bar. You say that your spine was fused, and this is for safety reasons. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar 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 pay for a grab bar purchased on March 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from November 9, 2019, to 
November 11, 2019. 
 
You asked the Plan to pay for the inpatient services. You say that you would like this claim to be reprocessed 
for payment. The Plan denied your request. The Plan says the information provided at the time of the appeal 
does not support medical necessity for inpatient hospitalization. 
 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 to pay for the inpatient services. Our reviewer says that 
the documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found based on the low complexity, low severity presentation and workup findings, it was not 
expected that the patient would require hospital services that would likely cross 2 midnights. 
 
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient services provided from November 9, 2019, to November 11, 2019.
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 you have been suffering with feet problems and need 
rehabilitation before another problem occurs. You say that you have poor blood flow and needed surgery to get 
blood from your legs to your toes. You say that your doctor has worked hard to save your leg. You say that you 
had a staph infection and are on antibiotics. You say that you have not healed, had a heart attack, and are on 
dialysis 3 times a week. You say that you have fallen twice since being let out of the hospital and your wife is 
afraid you will hurt yourself. The Plan denied your request. The Plan says the guidelines for coverage 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 [state the medical finding(s) upon which the physician based his/her conclusion] 
 
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 office visit provided on August 12, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that it was medically necessary to treat the enrollee. The 
Plan denied your request. The Plan says the rendering provider is an out-of-network provider with no approved 
authorization. Also, the referring provider is a non-participating provider. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 an office visit provided on August 12, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on September 16, 
2021, to September 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically 
necessary. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for skilled nursing facility services provided on September 16, 2021, 
to September 23, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the endoscopy and colonoscopy provided 
at a network facility on August 19, 2021, to September 3, 2021. 
 
You asked the Plan to waive the copayments for the endoscopy and the colonoscopy. You say that you are not 
responsible for the claims. You say you should have been categorized as low-income. The Plan denied your 
request. The Plan says you have been asked to pay 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 $300 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 
You have been asked to pay a $300 copayment for the endoscopy and a $300 copayment the colonoscopy. The 
endoscopy and the colonoscopy fall within the Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 
copayments for the endoscopy and colonoscopy provided at a network facility on August 19, 2021, to 
September 3, 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 you need to get out of the hospital and get 
rehabilitation. You say that you need IRF care after having the massive heart attack and you have not been able 
to walk. You say that you do not have the support you need at home. The Plan denied your request. The Plan 
says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the 
services needed in other settings. 
 
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 review has determined that 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 does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not require daily skilled therapy services on an 
inpatient basis. 
 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 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesions 
(11057) and the nail debridement (11721) rendered by the out-of-network (OON) provider on September 23, 
2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesions (11057) and the nail 
debridement (11721) rendered by the out-of-network (OON) provider on September 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided September 16, 
2021. 
 
You asked the Plan to pay for the office visit. You say that the provider does not accept the Plan and you have 
been paying the bills in full with your credit card each time you see her. She is your psychiatrist and you need 
to see her and you need to be reimbursed. The Plan denied your request. The Plan says if you go to a provider 
who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you 
receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit (99213) provided September 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brain FDG positron emission tomography (PET) 
services. 
 
You asked the Plan to pre-approve the brain FDG PET services. You say that the records provided support the 
need for the requested PET scan. The Plan denied your request. The Plan says the records show the enrollee has 
a known problem that affects her brain. The Plan says that there is no need to differentiate between FTD and 
Alzheimer's disease. 
 
The Plan follows Medicare rules. Medicare rules say that brain FDG PET services are only covered when a 
patient meets diagnostic criteria for both AD and FTD and a determination cannot otherwise be made on the 
diagnosis. 
 
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 brain FDG PET services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is not 
noted to meet the diagnostic criteria for both AD and FTD. While the enrollee is noted to have dementia, 
Medicare does not otherwise provide coverage of a PET/CT of the brain for classification of dementia except 
for the indication outlined in the NCD. In as much, this request cannot be said to be medically necessary 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 the brain FDG PET services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve brain FDG positron emission tomography (PET) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a destruction of skin growths procedure 
provided on September 28, 2021. 
 
You asked the Plan to waive the deductible for a destruction of skin growths procedure. You say that you were 
billed for hospital charges. You also say you were not seen at a hospital. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient surgery at an outpatient 
hospital.  
 
The records show you had a surgical procedure at an outpatient hospital, which is considered an additional 
service to a regular specialist office visit.  The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category 
outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible which applies to outpatient surgery at an outpatient hospital. This cost sharing is a contractual 
obligation that had not been met at the time a destruction of skin growths procedure was received on September 
28, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a destruction of skin 
growths procedure provided on September 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve the percutaneous vertebral augmentation. You say that you would like 
reconsideration because the requested procedure is medically necessary. The Plan denied your request. The 
Plan says the documentation does not show any advanced imaging. 
 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 percutaneous vertebral 
augmentation. 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 MRI or SPECT scan showing an acute 
vertebral fracture. More info is needed. 
 
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 percutaneous vertebral augmentation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on April 20, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that the attached records support the services 
billed and the claim should be reprocessed for payment. The Plan denied your request. The Plan says CPT code 
00412 has been overturned. The Plan also says that CPT code 99100 remains denied as bundled services are 
not eligible for separate payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).  
We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on April 20, 
2021.