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

 
We decided that the Plan does not have to waive the deductible for observation care provided on  
December 5, 2020. 
 
You asked the Plan to waive the deductible for the observation care. The Plan denied your request. The Plan 
says the claim paid leaving you with a responsibility of a $182.57 deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $182.57 deductible which applies to the observation care.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category of what is 
your plan deductible.  The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$500 deductible which applies to the observation care.  
 
 This cost sharing is a contractual obligation that had not been met at the time the observation care was received 
on December 5, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
observation care provided on December 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth care service provided on November 1, 2021. 
 
You asked the Plan to pay for a telehealth care service. The Plan denied your request. The Plan says you must 
use a network provider who offers the service by telehealth. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that if you choose to get services by telehealth, you must use a network provider who offers the 
service by telehealth. 
 
We looked at the file and the Plans rules. The requested provider in this case is not a network provider who 
offers this service by telehealth. Therefore, we decided that the Plan does not have to pay for a telehealth care 
service provided on November 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation. 
 
You asked the Plan to pre-approve lumbar facet joint radiofrequency ablation. You did not provide an 
argument with your appeal request. The Plan denied your request. The Plan says the patient does not meet 
criteria for the requested lumbar facet joint radiofrequency ablation. 
 
The Plan must follow Medicare rules. Medicare rules say that lumbar facet joint radiofrequency ablation is only 
covered for patients who have had at least two medically reasonable and necessary medial branch blocks, 
which each providing at least 80% sustained relief of primary pain. In this case, records show that the patient 
has only had one medial branch block.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lumbar facet joint radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar facet joint radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for treatment of a bladder lesion (51720) 
provided on July 29, 2021, and August 19, 2021. 
 
You asked the Plan to waive the copayment for the treatment of a bladder lesion. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing 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 $275 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 You have been asked to pay a $505.22 copayment for two treatments of a bladder lesion ($252.61 x 2 = 
$505.22), which is less than the standard $275 each. Treatments of bladder lesions fall within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for treatment of a bladder lesion (51720) provided 
on July 29, 2021, and August 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care aide services. 
 
You asked the Plan to pre-approve personal care aide services. You say that this should be covered because the 
enrollee cannot do activities of daily living on their own. The Plan denied your request. The Plan says the 
requested personal care aide services are not covered because the enrollee does not meet criteria for home 
health services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 personal care aide services. Our 
reviewer says that the enrollee does not meet criteria for home health (personal care) aide services.  
 
 Our physician reviewer found the medical records do not document the patient is receiving skilled home health 
nursing or therapy services (with a plan of care that is established and reviewed by a physician), which is 
required for the authorization of Medicare-covered home health aide services. The doctor also says that there is 
no documentation that the home health aide services meet Medicare criteria for reasonable and necessary to the 
treatment of the patients illness or injury by the skilled professional staff.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of personal care aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve personal care aide services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 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 pre-approve inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary.  
 Our physician reviewer found based upon review of the records provided this enrollee does not meet the 
criteria for April 2, 2022, forward as this enrollee was not shown to be a danger to herself or others. There were 
no delusions, auditory or visual hallucinations noted. She was cooperative/compliant with treatment while not 
showing any threats to the safety of herself or others. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 25, 2021. 
 
You asked the Plan to pay for the medical services. You say that you have added a modifier to the claim, so it 
should be paid. The Plan denied your request. The Plan says the patient was enrolled in hospice on the date of 
service in question. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service September 6, 
2021. 
 
You asked the Plan to pay for procedure code 99284. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says another provider within your same 
group (billing under the same National Provider Identifier (NPI)) also billed for an evaluation and management 
code (code 99291) on this same date of service, so a second evaluation and management code is not covered. 
 
 The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice who are in 
the same specialty must bill and be paid as though they were a single physician. If more than one evaluation 
and management service is provided on the same day to the same patient by the same physician or more than 
one physician in the same specialty in the same group, only one evaluation and management service may be 
reported. That was the case here.  Another provider with the same specialty from the same group already billed 
for and was paid for an evaluation and management code for this patient on this date of service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99284 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99284 billed for date of service September 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 19, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you need more time to get authorization. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
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 office visit provided on November 19, 2021 by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information we have about your 
condition; you don't meet all the requirements. 
 
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 medically necessary. Our physician reviewer found that based on the medical 
records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide 
medically necessary and reasonable treatment. The records do not document the need for intravenous 
medications, new tube feeding, or ostomy care or daily complex wound care. You do require skilled therapy 
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and 
effectively provide medically necessary and reasonable treatment. There is no documentation that daily skilled 
services are required. You are walking household distances with a rolling walker with contact guard to stand-by 
assistance and is contact guard assist for transfers. The provided records do not document a significant decline 
in your functional status to necessitate daily inpatient skilled therapy services. As a practical matter, there is no 
documentation that you require the services on an inpatient basis, only in a skilled nursing facility setting. 
Services in the home with home health care or in a long-term care facility on a part time basis appear 
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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284) provided September 16, 
2021. 
 
You asked the Plan to pay for the emergency room services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this service shares a bundled relationship with another 
service billed and is not separately payable. 
 
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 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for emergency room services (99284) provided September 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97110) provided on October 6, 2021. 
 
You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for the therapy services (97110) provided on October 
6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need physical therapy and medical assistance. 
The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44960 billed for date of service July 9, 2021. 
 
You asked the Plan to pay for procedure code 44960. You say that these services were billed correctly. The 
Plan denied your request. The Plan says procedure code 44960 is not supported in the medical record and there 
is a more appropriate code that should have been 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. 
 
In this case, the CPT Code Manual definition of code 44960 is Appendectomy; for ruptured appendix with 
abscess or generalized peritonitis. 
 
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 procedure code 44960. Our reviewer says that procedure 
code 44960 is not supported in the medical record. Our reviewer found the operative report describes a 
appendectomy with muccocele.  To cite the operative report "The appendix was identified and the appendix was small, but the tip was marked and was dilated as into a muccocele.  The mesoappendix was then taken 
down using the LigaSure down to the vase of the appendix where this was then suture ligated with 3-0 silk and 
the appendix was removed and sent for frozen section intact".  Documentation does not support the appendix 
was ruptured, and therefore this procedure cannot be verified.  There is a more appropriate code to report for 
service provided.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 44960 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 44960 billed for date of service July 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says 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 the skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is 
ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not 
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 the skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a position emission tomography (PET) scan of the entire 
body. 
 
You asked the Plan to pre-approve a PET scan of the entire body. 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. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET scan of the entire body. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the rationale for a 
PET/computed tomography (CT) in an enrollee with known diffuse metastases has not been explained by the 
referring clinician. Absent this information the medical necessity of a PET/CT in an enrollee reported to have 
diffuse osseous metastases via CT scan and allegedly conventional radionuclide bone scan has not been 
established. 
 
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 PET scan of the entire body have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a position emission tomography (PET) scan of the entire body.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injection services. 
 
You asked the Plan to pre-approve the facet joint injection services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for facet joint injections to be covered, 
there must be a documented failure of pain to respond to noninvasive conservative care. 
 
We looked at the file and Medicare rules. In this case, there is no evidence of conservative care having been 
performed prior to the request for these injections. Based on this information, we decided that Medicare rules 
for coverage of the facet joint injection services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the facet joint injection services.