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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery and follow up office 
visits provided from August 17, 2021, to September 10, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery and follow up office visits. You say that if 
the original surgery was done correctly, you wouldn't have had to have more procedures done. You believe 
these services should be covered. The Plan denied your request. The Plan says the copayments applied are 
correct. 
 
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 $350 
copayment per date of service for outpatient surgery at an outpatient hospital facility and a $40 copayment per 
visit to a specialist.  
You have been asked to pay $350 copayment for each outpatient surgery and a $40 copayment for each of the 
follow up office visits. The total amount you owe is $780 ($350 + $350 + $40 + $40 = $780).  Outpatient 
surgery falls within the Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers. The office visits fall within the Physician/Practitioner services, including doctors 
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 outpatient surgery and 
follow up office visits provided from August 17, 2021, to September 10, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) provided December 
4, 2021. 
 
You asked the Plan to pay for the emergency visit. You say that this CPT 99284 does not require a modifier 
when this is the only CPT billed by this provider. Please review and reprocess correctly. The Plan denied your 
request. The Plan says the procedure code is inconsistent with the modifier used. 
 
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 99284 is Emergency department visit 99285 is used for 
the evaluation and management of a patient, which requires these 3 key components: a comprehensive history, 
a comprehensive examination; and medical decision making of high complexity. 
 
We find that CPT code 99284 is not supported in the medical record. Specifically, services rendered to incarcerated members are not payable. In accordance with the foregoing statutory and regulatory provisions, 
Medicare excludes from coverage items and services furnished to beneficiaries in State or local government 
custody under a penal statute, unless, it is determined that the State or local government enforces a legal 
requirement that all prisoners/patients repay the cost of all healthcare items and services rendered while in such 
custody and also pursues collection efforts against such  individuals in the same way, and with the same vigor, 
as it pursues other debts. CMS presumes that a State or local government that has custody of a Medicare 
beneficiary under a penal statute has a financial obligation to pay for the cost of healthcare items and services. 
Based on this information, we decided that Medicare rules for coverage of the emergency visit have not been 
met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) 
provided December 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 5, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is excluded 
from coverage. 
 
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 services provided on January 5, 
2022. have been met. The submitted documentation does not contain medical records from the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, 
we decided that the Plan does not have to pay for the services provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (ESI). 
 
You asked the Plan to pre-approve the repeat ESI. You say that you would like reconsideration because the 
requested ESI is medically necessary. The Plan denied your request. The Plan says the requested epidural 
steroid injection does not meet the Medicare LCD coverage 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 the repeat ESI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee did not have at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale for at least three (3) months. She 
reported that the injection did not work at all.  In addition, though the provider requested for the procedure to 
be performed under conscious sedation, the same procedure/approach (TFESI) at the same level (L5-S1) was 
requested. There is no indication that a different approach, level, or medication will be used for the injection. 
 
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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat epidural steroid injections (ESI).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 
27, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you were told the service 
would be covered since you were going to a rehab center. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 $225 
copayment for per one-way trip for Medicare covered ambulance services. 
  
 
 
 You have been asked to pay $225 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 copayment for ambulance transport 
provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for wound care services performed on January 
20, 2022. 
 
You asked the Plan to reduce the copayment for the wound care. You say that you feel you should only have a 
$35 copayment for a specialist 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 $295 
copayment for surgery or other services provided at an outpatient hospital.  
 
You have been asked to pay a $295 copayment for the wound care. The wound care falls 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 reduce the copayment for wound care services performed on January 20, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you 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 you 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service December 
27, 2021. 
 You asked the Plan to pay for procedure code G0453. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for G0453 is bundled into payment for 
code 95955. 
 
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 G0453 
is a column II code to column I code 95955. 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 G0453 billed for date of service December 27, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (ESI). 
 
You asked the Plan to pre-approve repeat ESI. You say that you would like reconsideration because the 
requested ESI is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage. 
 
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 repeat ESI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the request does not meet the criteria as listed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat epidural steroid injections (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee from 
September 8, 2021, to September 20, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for 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 must 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 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 out of network services provided to the enrollee 
from September 8, 2021, to September 20, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (11971) provided November 17, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the records do not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the surgical services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee had an infected breast prosethesis (tissue expander) that had been 
placed after mastectomy breast cancer. The operative note describes an infected field and the removal of the 
expander, consistent with the definition of the billed CPT code. The record provided establishes the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
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 services have been met. Therefore, we decided that the Plan has to 
pay for surgical services (11971) provided November 17, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee 
on November 1, 2021. 
 
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for this transport. 
 
Medicare rules say that plans can require enrollees to get care prior authorization. The contract with the Plan 
says that non-emergent ambulance transport requires prior authorization. The provider in this case is not a 
network provider with the Plan. The Plan did not pre-approve this service. Therefore, we decided that the Plan 
does not have to pay for non-emergent ambulance transport provided to the enrollee on November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker purchased out of network on November 23, 2021. 
 
You asked the Plan to pay for this item. You say that the Plan should pay for this equipment. The Plan denied 
your request. The Plan says this equipment was purchased out of network without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees must use network providers. The contract specifically states durable medical equipment 
is not covered out of network. The Plan did not pre-approve the item at issue. We found no exception that 
would require the Plan to pay for this walker. Therefore, we decided that the Plan does not have to pay for a 
walker purchased out of network on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic drug assays and column chromatography/mass 
spectrometry provided to the enrollee on April 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says charges in connection with services that experimental and investigational are excluded from 
coverage. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that these services would be considered experimental and investigational, and are excluded from 
coverage.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for therapeutic drug assays and column chromatography/mass spectrometry provided to the 
enrollee on April 6, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for thoracic laminectomy. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Favorable

 
We decided that the Plan has 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 that 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 the 
service is medically necessary. Our physician reviewer found you did not have documented skilled nursing 
needs. You did have documented skilled therapy needs. You were functioning below your baseline. Daily 
skilled services were reasonably required to establish a maintenance program and/or to prevent deterioration of 
your condition. As a practical matter, because you live alone, services could not be provided at a lower level of 
care. You continue to improve while in the hospital and this supports that you would benefit from 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 care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response with no transport provided on January 
29, 2022. 
 
You asked the Plan to pay for response with no transport. You say that you believe this bill should be covered 
by the Plan. The Plan denied your request. The Plan says Medicare does not cover ambulance response without 
transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The ambulance company did not provide transport services on January 29, 2022. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response 
with no transport provided on January 29, 2022.