Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need skilled nursing to improve my 
condition to return home and back to normal living. The Plan denied your request. The Plan says that continued 
training to meet your needs does not have the complexity that would require daily therapy intensity. 
 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 your 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on November 4, 2021. 
 You asked the Plan to pay for the eye refraction. You say that you see this provider on a yearly basis and feel 
you should not have to see another provider for routine services. The Plan denied your request. The Plan says 
the provider in this case is not part of the specified routine vision vendor network. Eye refractions are not 
covered by Original Medicare, and are only covered by the Plan when they are received as part of a routine eye 
exam from a provider in the specified network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided as part of a routine eye exam performed by a 
provider within the specified routine vision vendor network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans routine vision 
network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on 
November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT code 64493).  
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 service. Our physician reviewer 
found the enrollee has an alternative probable pain generator in their sacroiliac (SI) joints. The enrollee has not 
had three (3) full months of conservative therapy documented. Therefore, the criteria of the LCD are not met 
and at this point, the request is deemed not medically reasonable or 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
code 64493).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health inpatient services provided from 
September 14, 2021, to November 22, 2021. 
 
You asked the Plan to pay for the behavioral health inpatient services. You say that this was involuntary, and 
court ordered hospitalization. The Plan denied your request. The Plan says you do not meet the requirements 
for coverage. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 behavioral health inpatient services. Our 
reviewer says that you do not meet the Medicare criteria for inpatient psychiatric care provided from 
September 14, 2021, to November 22, 2021. Our physician reviewer found it was not expected you would 
improve in a reasonable period of time as you did not have dangerousness to yourself or others, auditory or 
visual hallucinations, delusions and were not showing any behavioral issues. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than 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 behavioral health inpatient services have not been met. Therefore, we 
decided that the Plan does not have to pay for the behavioral health inpatient services provided from September 
14, 2021, to November 22, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbar or sacral epidural injection. 
 
You asked the Plan to pre-approve a lumbar or sacral epidural injection. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Epidural Steroid Injections are covered when specific 
criteria are met. 
 
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 a lumbar or sacral epidural injection. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the request is 
medically reasonable and necessary as the LCD criteria are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar or sacral epidural injection have been met. Therefore, we decided that 
the Plan has to pre-approve a lumbar or sacral epidural injection.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health aide and skilled nursing 
services. 
 You asked the Plan to pre-approve home health services. You say that you have a hard time cleaning or picking 
up things from the floor. You say that you cannot be on your feet. You say that there is very little that you can 
do on your own. You also say that you would like your hours to remain the same. The Plan denied your 
request. The Plan says additional home health services are not medically necessary. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
documentation does not support that you require additional skilled nursing services or home health aide 
services to provide treatment that is medically necessary. The reviewer found that you do not require additional 
skilled nursing or home health aide services to effectively provide treatment, care, and/or services in order to 
improve your condition, perform a maintenance program to maintain your condition and/or prevent 
deterioration. The reviewer found that you have been medically stable without any recent exacerbations of 
chronic medical problems or hospitalizations. Therefore, the reviewer found that the requested home health 
services are not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health aide and skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (74018) provided October 17, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support more than one instance of code 
74018. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 74018 is not supported in the medical record. Specifically, the claim is a duplicate. 
Code 74018 was already paid under claim number RAM3652494300. Records do not support multiple units of 
this code. Based on this information, we decided that Medicare rules for coverage of the radiology services 
have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (74018) 
provided October 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care visit, first 30-74 minutes (99291) provided June 
7, 2021. 
 
You asked the Plan to pay for the critical care visit. You say that you would like to appeal this determination. 
This service does support the level of service assigned and was warranted and is considered medically 
necessary. The Plan denied your request. The Plan says the records do not support the billed service. 
 
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 99291 is evaluation and management of the critically ill 
or critically injured patient, first 30-74 minutes.  
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The 
documentation does not include the time spent providing this service, therefore, the billed Critical Care 
evaluation and management code cannot be verified. It is noted that multiple attempts were made to contact the 
provider for additional information without success. Based on this information, we decided that Medicare rules 
for coverage of the critical care visit have not been met. Therefore, we decided that the Plan does not have to 
pay for critical care visit, first 30-74 minutes (99291) provided June 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient behavioral health services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient behavioral health services to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
outpatient behavioral health services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is 
walking with a wheeled walker with stand-by assistance, propelling in a wheelchair up to 400 feet with 
modified independence and is supervision for transfers. The enrollee does not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Records do not document that services in a long-term 
care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 8, 
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 this is an add-on code, and the primary procedure was not allowed. 
 
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 the 
services is an add-on code and has not been billed with an appropriate primary procedure code.  Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory services provided to the enrollee on October 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
October 4, 2021 to October 29, 2021. 
 You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not submitted with a valid type 
of bill or a required Q code. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was not submitted with a valid Type of Bill code for Home Health services. Additionally, this claim was not 
billed with one of the required Q codes. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from October 4, 2021 to October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the billed codes do not have a TC payment. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 12, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an audiology office visit received on October 4, 2021. 
 
You asked the Plan to pay for the services. You say that you were told that these services would be covered 
with a back-dated referral. The Plan denied your request. The Plan says that the denied code cannot be reported 
by an audiologist. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the services by a contract provider. The file does not show that the Plan provided notice 
that certain codes cannot be reported by audiologists. You were told that it was ok to get a back-dated referral 
for the services, and the plan ended approving the audiology exam. You have no control over how the 
audiology provider bills the services. Under Medicare rules, this means the services are considered approved by 
the Plan. Therefore, we decided that the Plan has to pay for an audiology office visit received on October 4, 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold pack therapy (97010) provided on November 
19, 2021. 
 
You asked the Plan to pay for the hot or cold pack therapy. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says CPT code 97010 has a status indicator 
of B. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the hot or cold pack therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
the hot or cold pack therapy (97010) provided on November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82542, G0480, 80307, 84228) provided on 
December 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. The services were not emergent or 
pre-authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
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 lab services (82542, G0480, 80307, 84228) provided on December 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient office visit provided on December 15, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were 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 Outpatient office visit provided on December 15, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 16, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that it was medically necessary for the services 
rendered and would like the claim reprocessed for payment. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service 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 the laboratory services provided on December 16, 
2021, by an out-of-network (OON) provider.