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

 
We decided that the Plan does not have to pre-approve the MinutemanTM interspinous interlaminar fusion 
device. 
 
You asked the Plan to pre-approve the MinutemanTM procedure. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 MinutemanTM procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MinutemanTM device is experimental. More research is needed before 
coverage can be approved. 
 
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 MinutemanTM procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MinutemanTM interspinous interlaminar fusion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthetic foot and knee (L5822, L5845, 
L5850, L5781, L5986, L5981). 
 
You asked the Plan to pre-approve the replacement prosthetic foot and knee. You say that these prosthetics 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 coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot or knee. 
 
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 replacement prosthetic foot and 
knee. Our reviewer says that the requested prosthetics are not medically necessary. Our physician reviewer 
found the requested foot and knee include K3 features. The records show that the enrollee ambulates at a K2 
level. The requested features exceed the enrollee's needs. 
 
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 replacement prosthetic foot and knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a replacement prosthetic foot and knee (L5822, L5845, 
L5850, L5781, L5986, L5981).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 13, 2021 billed with 
codes 81220, 81226, 81227, 81230, 81238, 81241, 81291, 81335, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
  
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 13, 2021 billed with codes 81220, 81226, 81227, 81230, 81238, 81241, 81291, 81335, and 81355.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you have a blood infection and a lot of 
fluid build-up. You say that it is not safe for you to be discharged home as you are unable to care for yourself 
and you need physical therapy to regain your strength. The Plan denied your request. The Plan says your needs 
can be met at a lower level of care and higher caregiver availability may be required going forward which her 
family appears to have recognized. 
 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 admission. Our reviewer says that 
you received oral medications and you have stable vital signs. You were at supervision to independent level for 
functional mobility including gait to 200 feet with a rolling walker. You required varying assist with activities 
of daily living. Our physician reviewer found 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. 
Our reviewer also found that you do 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the SNF admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 20, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the tests are included in the 
dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on October 7, 2021. 
 
You asked the Plan to pay for the services provided. You say that charges are coded correctly for this service. 
The Plan denied your request. The Plan says the procedure is included in the global surgery package. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 36589 was billed during the global surgery period for procedure code 36558. 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 surgery services provided on October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes. 
 
You asked the Plan to pre-approve foot orthotics. You say that the shoes are to improve your quality of life 
after hip replacement. 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.   
 
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 pre-approve orthopedic shoes.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no evidence that there is a reduction in the intensity and frequency 
of your symptoms or findings. 
 
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 additional 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 that the clinical documentation shows that initial physical therapy 
sessions were related to assessment and treatment of back pain and patient was undergoing a stable home 
exercise plan for this diagnosis. There is a letter by you staying that you suffered a stroke which could qualify 
you for additional physical therapy for an alternative diagnosis; however, there is no clinical documentation by 
physical therapist or order by provider for physical therapy related to functional impairments secondary to 
stroke thus at this point for back pain 16 additional physical therapy sessions is 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 the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the eye drug and related injection services 
provided from February 10, 2022, through March 24, 2022. 
 
You asked the Plan to waive the cost share for the eye drug and related injection services. You say that the cost 
share is too expensive for your means. The Plan denied your request. The Plan says the cost share for these 
services has processed 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 $40 
copayment for Medicare-covered Vision Services and a 20% coinsurance for Medicare Part B Prescription 
Drugs 
 
You have been asked to pay a $40 copayment for the injection administration services and a 20% coinsurance 
for the eye drugs. The eye drug and related injection services falls within the for Medicare-covered Vision 
Services and 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 
cost share for the eye drug and related injection services provided from February 10, 2022, through March 24, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains 
not supported. 
 
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 October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on April 27, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like to appeal the cost 
share. 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 $30 
copayment for an office visit.  
 
You have been asked to pay a $30 copayment for an office visit. An office visit falls 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 an office visit on April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550) provided February 4, 
2022. 
 
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 these services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for lab services (82728, 83540, 83550) provided February 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee does meet LTAC admission 
criteria and ongoing medical needs warrant an LTAC level of care to achieve a safe and sustainable discharge. 
The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services you are 
requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee with end-stage congestive heart failure (CFH) was admitted to the 
hospital on August 3, 2022 for confusion. The enrollee was found to have cellulitis of both legs and was treated 
with intravenous antibiotics and intravenous diuretics. The record states the enrollee has a poor prognosis and 
that palliative care or hospice is appropriate. The enrollee has also been receiving would care services. The 
enrollee is receiving appropriate care at the present setting. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care. The Plan denied 
your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on January 17, 2022, to 
February 8, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. We find that a timely-filed notice of admission was not submitted. Based on 
this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided on January 17, 
2022, to February 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for 23 occupational therapy (OT) visits 
provided from January 5, 2022, to March 30, 2022. 
 
You asked the Plan to waive the copayment for the OT visits. The Plan denied your request. The Plan says the 
copayment was applied 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 $20 per 
individual therapy visit for San Diego county plan members.  
 
You have been asked to pay $460 for the OT visits. The OT visits fall within the Outpatient Rehabilitation 
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 23 occupational therapy 
(OT) visits provided from January 5, 2022, to March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81599) provided on March 29, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory services (81599) provided on March 
29, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation services 
for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87510 and 87641 billed for services 
provided on August 31, 2021. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. 
 
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 code 87510 is a column II code to column I code 87500. We also find that code 87641 is a column 
II code to column I code 87150. The claim information shows that the services at issue have 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 codes 87510 and 87641 
billed for services provided on August 31, 2021.