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

 
We decided that the Plan does not have to pre-approve epidural steroid injections (64483). 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections are covered when 
the first injection directly and significantly provided improvement of the condition being treated, and the 
medical record documents at least 50% of sustained improvement in pain relief and/or improvement in 
function.  
 
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 epidural steroid injections. Our 
reviewer says that the injections are not medically necessary. Our physician reviewer found there is a lack of 
documentation of the results of the last two injections. Without this documentation, repeat injections are not 
supported. 
 
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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (64483).
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
 
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: 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 IRF care to return to the same quality of 
life you had before. The Plan denied your request. The Plan says your records do not show that you meet 
criteria for an IRF admission. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary 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. 
 
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 a catheter placement in coronary artery(s) for coronary 
angiography (93458), initial observation care (99220), and physician services (99152) provided on January 29, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a catheter placement in coronary artery(s) for coronary angiography, initial 
observation care, and physician services. You say that the enrollee was moved from her hospital room at one 
facility and carried to another hospital. You also say that you are her caretaker and had no knowledge of this 
until the next day, where you immediately called the business office of the new hospital and were told they 
would take care of the prior authorization. The Plan denied your request. The Plan says this provider is not a 
contracted provider with the Plan. 
 
 
 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 a catheter placement in coronary artery(s) for 
coronary angiography (93458), initial observation care (99220), and physician services (99152) provided on 
January 29, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the intensive care services provided from 
January 13, 2021, to January 17, 2021. 
 
You asked the Plan to waive the copayment for the intensive care services. You say that you cannot afford this 
amount. 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 a $200 
copay per day for days 1-5 for each inpatient stay.  
 
 
 
 You have been asked to pay a $200 copay per day for the intensive care services. Your stay was from January 
13, 2021, to January 17, 2021, a total of 5 days, bringing your total copay to $1000. The intensive care services 
fall within the Inpatient hospital care 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 
the intensive care services provided from January 13, 2021, to January 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an electrocardiogram (ECG), routine with at least 12 leads (93010) 
rendered on January 29, 2021. 
 
You asked the Plan to pay for an electrocardiogram (ECG), routine with at least 12 leads. You say that the 
patient was moved from her hospital room at one facility and carried to another facility. You also say that you 
are her caretaker and had no knowledge of this until the next day. You also say that you immediately called the 
business office of the current facility and was told they would take care of the prior authorization. The Plan 
denied your request. The Plan says that the provider is not a contracted provider with the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to send the correct Evidence of Coverage for this date of service. 
The Plan sent their 2020 Evidence of Coverage (EOC) and the date of service happened on January 29, 2021. 
The Plan should have submitted their 2021 EOC. Therefore, we decided that the Plan has to pay for an 
electrocardiogram (ECG), routine with at least 12 leads (93010) rendered on January 29, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (procedure codes 87486, 87541, 87581, 87631, 
87640, 87798, and G2023) provided on July 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that provider signatures are not required during the 
COVID-19 pandemic. The Plan denied your request. The Plan says you billed these services with an incorrect 
place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (procedure codes 87486, 87541, 87581, 87631, 87640, 87798, 
and G2023) provided on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided June 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81479) provided June 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
March 18, 2022. 
 
You asked the Plan to pre-approve the continued SNF care. You say that SNF care is medically necessary and 
supported by the records provided. The Plan denied your request. The Plan says there are no noted daily skilled 
complex nursing or therapy needs. 
 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 the continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who 
was admitted to the SNF on 3/3/2022. As of 3/16, she required minimal assist to sit up, standby assist to scoot, 
and standby/contract guard assist to stand. She required contact guard assist to walk up to 30 feet.  
 
The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs are custodial and intermittent and can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond March 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 occupational therapy visits. 
 
You asked the Plan to pre-approve the occupational therapy visits. You say that say the medical records 
provided support the necessity of the services. The Plan denied your request. The Plan says the records do not 
support that the enrollee meets the criteria for the requested services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the occupational therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the enrollee has had prior OT and the documentation 
does not reveal that the patient requires the unique skills of a professional therapist to safely and effectively 
provide treatment, or that the services can be safely and effectively performed only by a therapist or by or 
under the supervision of a therapist. The enrollee is compliant in a home exercise program. The requested 
services are not part of a maintenance program and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current 
condition or to prevent or slow further deterioration. 
 
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 occupational therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 16 occupational therapy visits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 01830-QX-QS-P3 billed for date of service September 
3, 2021. 
 
You asked the Plan to pay for procedure code 01830-QX-QS-P3. You say that you have provided medical 
records to substantiate payment. The Plan denied your request. The Plan says that this is an exact duplicate of 
another claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole denial rationale in this case is that the claim in 
question for procedure code 01830-QX-QS-P3 is an exact duplicate of another claim.  However, the only other 
claim submitted in this file by the Plan is not an exact duplicate.  The other claim provided by the Plan is for 
the same date of service, but for a completely different code.  The other claim is for 30 minutes of procedure 
code 00811-QX-QS-P2 related to only one diagnosis (R194.)  The claim in question in this appeal is for 114 
minutes of code 01830-QX-QS-P3, related to three separate (and different) diagnosis codes: M869, I120, 
N186, and F17200.  Because these were the only two claims submitted by the Plan in their case submission to 
us, we can only assume that these are the two claims that the Plan is calling 'duplicates.'  As noted above, these 
claims are not duplicates of one another.  The Plan has provided no other basis to support its denial. Therefore, 
we decided that the Plan has to pay for procedure code 01830-QX-QS-P3 billed for date of service September 
3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on November 9, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient visit. You say that you would like the appointment to be paid. The 
Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there was no 
referral from the enrollee's primary care physician or was not approved in advance. Also, the services rendered 
was not urgent or emergent. 
 
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 outpatient visit provided on November 9, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for observation care (99217) rendered on January 30, 2021. 
 
You asked the Plan to pay for observation care. You say that the patient was moved from her hospital room at 
one facility and carried to another facility. You also say that you are her caretaker and had no knowledge of this 
until the next day. You also say that you immediately called the business office of the current facility and was 
told they would take care of the prior authorization. The Plan denied your request. The Plan says that the 
provider is not a contracted provider with the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to send the correct Evidence of Coverage for this date of service. 
The Plan sent their 2020 Evidence of Coverage (EOC) and the date of service happened on January 30, 2021. 
The Plan should have submitted their 2021 EOC. Therefore, we decided that the Plan has to pay for 
observation care (99217) rendered on January 30, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection (J0585) 
provided on August 17, 2021. 
 
You asked the Plan to waive the coinsurance for the onabotulinumtoxina injection. You say that the services 
should be covered as you were not aware the coinsurance would be so high beforehand. The Plan denied your 
request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 20% 
coinsurance for Medicare Part B Prescription Drugs and the administration of them. 
 
 
  You have been asked to pay a 20% coinsurance for the onabotulinumtoxina injection (allowed is $800 x 20% = 
$160). Onabotulinumtoxina injections fall within the Medicare Part B Prescription Drugs 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 coinsurance for an onabotulinumtoxina botox injection (J0585) provided on 
August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.