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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve SI RFA. You say that ablation is the next step in your treatment. The Plan 
denied your request. The Plan says this procedure has not been show to provide a clear long-term benefit over 
standard treatments. 
 
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 SI RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and is non-covered. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found Interspinous spacer devices are experimental. More research is needed to show 
safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug test provided on April 6, 2022. 
 
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says only one test is 
payable per date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that a maximum of one presumptive urine drug test 
may be submitted and paid per patient date of service.  
 
We looked at the file and Medicare rules. The records show that a presumptive drug test provided by another 
provider was paid for the same date of service. As such, the requested presumptive drug test is not payable. 
Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. 
Therefore, we decided that the Plan does not have to pay for the presumptive drug test provided on April 6, 
2022.
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 you are having a difficult time with strength and 
mobility. The Plan denied your request. The Plan says based on Medicare guidelines, the requested SNF 
services do not meet the requirements for approval. 
 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
February 25, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless they are authorized by the Plan before the 
services are provided. 
 
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 
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 subsequent nursing facility care provided on February 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laparoscopy, surgical, gastric restrictive procedure; 
with gastric bypass and small intestine reconstruction to limit absorption (CPT code 43645). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the documentation submitted by your doctor indicates that you at the time of the request 
have a BMI of less than 35. 
 
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 services. Our physician reviewer 
found you have a BMI that is less than 35 kg/m2. The Medicare rules state that the enrollee's must be greater 
than or equal to 35 kg/m2. 
 
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 pre-approve the laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small 
intestine reconstruction to limit absorption (CPT code 43645).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo System (CPT code(s): 0266T and 
C1825). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Barostim Neo System in the setting of 
congestive heart failure have not been demonstrated in the peer-reviewed literature. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Barostim Neo System (CPT code(s): 0266T and C1825).
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
You asked the Plan to waive the coinsurance for and pay for inpatient hospital care provided on May 11, 2022.. 
You say that this should not be considered out-of-network because you were referred on an emergency basis. 
The Plan says that this cost sharing was charged correctly and the Plan will not make additional payment. 
 
We decided that the Plan has to reduce the coinsurance for inpatient hospital care.  
 
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 enrollees pay 35% 
coinsurance for out-of-network inpatient hospital care. The allowed amount of the inpatient stay is $5,716.99, 
resulting in a coinsurance amount of $2,000.95. 
 
The Plan says you must pay $2,219.14 coinsurance amount, which is more than 35% coinsurance for inpatient 
hospital care. Based on your contract with the Plan; however, you cannot be asked to pay more than $2,000.95 
coinsurance amount, which is 35% coinsurance for inpatient hospital care. Therefore, we decided that the Plan 
has to reduce the coinsurance amount for inpatient hospital care from $2,219.14 to $2,000.95.  
 
We also decided that the Plan does not have to waive the coinsurance for and pay for inpatient hospital 
care. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Medicare rules say that when services or supplies are rendered by a 
non-contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or 
the enrollee. 
 
Your contract with the Plan clearly says that you must pay 35% coinsurance for inpatient hospital care. The 
allowed amount of the claim is $5,716.99, resulting in a coinsurance amount of $2,000.95. After the Plan has 
complied with the requirement to adjust your coinsurance responsibility to the appropriate amount, the Plan 
will have paid up to the Medicare allowable amount for this claim, less the applicable cost-sharing. A Medicare 
provider should accept the Medicare allowed amount as payment in full. Therefore, the Plan is not responsible 
for paying the balance that remains above the Medicare allowed amount. Therefore, we decided that the Plan 
does not have to waive the coinsurance for and pay for inpatient hospital 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the service is experimental and is non-covered. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered investigational. More research is needed to show safety and 
efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are experiencing balance issues, weakness, gait 
issues, and are unable to do steps to return home safely. The Plan denied your request. The Plan says this is not 
medically necessary under Medicare guidelines. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 30, 
2022, to April 28, 2022. 
 You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no 
longer required daily skilled services at an inpatient SNF 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 pay for the SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) care provided from March 30, 2022, to April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the provider does not do ear 
implants for hearing. The Plan denied your request. The Plan says a network provider can care for your medical 
problem. 
 
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 
the services to be provided by an out-of-network provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 physical therapy (PT) visits (G0151 x10). 
 
You asked the Plan to pre-approve the PT visits. The Plan denied your request. The Plan says that the medical 
record does not document a clearly evident need for the services of a skilled physical therapist. The Plan also 
says that there is no documentation of an active or acute on chronic condition that would necessitate a new 
program. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 PT visits. Our reviewer says that the 
10 PT visits are reasonable and necessary for the enrollee. Our physician reviewer found the clinical 
documentation does show that the enrollee is home bound, has neurological and functional impairments, and 
had a recent change in functional/clinical status due to a fall, thus 10 home health PT visits are medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PT visits have been met. Therefore, we decided that the Plan has to pre-
approve 10 physical therapy (PT) visits (G0151 x10).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99204) provided on February 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter."  
We find that CPT code 99204 is not supported in the medical record. Specifically, the records show that the 
enrollee was seen by a provider of the same specialty and group practice on April 15, 2021. As such, the 
requested visit would not be considered a new patient visit. 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 the services (99204) provided on February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aortography and angiography (procedure codes 75630, 
75774) provided to the enrollee on May 12, 2022. 
 
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 the codes cannot be verified. 
 
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 the denied codes is: 
 
CPT 75630: 
 
Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological 
supervision and interpretation 
 
 
 CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the guidelines do not permit 
separate charges for vascular studies which would be for the purpose of roadmapping for an interventional 
procedure as is the case for this patient. The aortogram and bilateral iliofemoral and selective lower extremity 
angiogram would be considered a necessary analysis as part of the performed procedure - CPT 37229 - and 
would thus not be as a separate and and unrelated procedure. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for aortography and angiography (procedure codes 75630, 75774) provided to the enrollee on May 
12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cataract surgeries provided on April 
25, 2022, to May 02, 2022. 
 
You asked the Plan to reduce the copayment for the cataract surgeries. You say that you were under the 
impression that the facility was an ambulatory surgical center and your copayment would be $145. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $550 
copayment for outpatient hospital facility visits. 
 
You have been asked to pay a $550 copayment for the cataract surgeries. This item/service falls within the 
outpatient hospital facility 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. The file shows that you had two cataract surgeries at an outpatient hospital from 
April 25, 2022, to May 2, 2022. The $275 copayment applies to each, for a total of $550. Therefore, we decided that the Plan does not have to reduce the copayment for the cataract surgeries provided on April 25, 
2022, to May 02, 2022.