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

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 19, 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 were not billed correctly. 
 
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 these 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 the laboratory services rendered on October 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inpatient hospital services provided from April 17, 
2022, through April 19, 2022. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that records do not show these services are necessary 
for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary.  The enrollee presented to the hospital with right foot and knee pain following a fall at home. X-rays showed 
fractures. The orthopedic surgeon suggested conservative management only (no surgery). The enrollee was 
already on pain medications prior to admission and tolerating them. There was no significant change of 
treatment was offered on admission, except for physical therapy. Based on the provided documentation, the 
patient did not appear to require hospital services that would likely cross 2 midnights as the patient was stable. 
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of inpatient 
hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the inpatient hospital services provided from April 17, 2022, through April 
19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram rendered on November 1, 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 procedure code 77065 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 0, the Column 2 code is not payable. 
 
The provider submitted a claim for procedure codes 77065 (diagnostic mammography, including computer-
aided detection, unilateral) and 77066 (diagnostic mammography, including computer-aided detection, 
bilateral).  
 Code 77065 is a column II code with a modifier indicator of 0 when billed with column I code 77066. Code 
77065 is not separately payable. Therefore, we decided that the Plan does not have to pay for the mammogram 
rendered on November 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint 
(SIJ) nerves. 
 
You asked the Plan to pre-approve the SIJ RFA procedure. You say that although this is not proven to be 
effective in clinical trials, the treatment is clearly helpful for this particular patient. The Plan denied your 
request. The Plan says while this may be helpful for this patient, it is still considered experimental as the 
efficacy is not proven. 
 
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 SIJ RFA procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a female with SIJ pain. She had Left lateral sacral nerves RFA on 
8/10/20. That procedure gave her 80-90% pain relief along with a decrease in medication usage and an increase 
in mobility for about one year. The request is for repeat RFA. 
 
This is an experimental/ investigational procedure. The literature shows wide variation in efficacy. Therefore, 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 SIJ RFA procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint (SIJ) nerves.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy services (97140, 97110 and 97165) provided on June 
10, 2021, through June 25, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that this provider is not eligible for 
payment. 
 
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 has not forwarded any evidence to support why this 
provider is ineligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided 
that the Plan has to pay for physical therapy services (97140, 97110 and 97165) provided on June 10, 2021, 
through June 25, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for inpatient hospital services provided from 
August 22, 20201, to August 26, 2021. 
 
You asked the Plan to reduce the coinsurance for inpatient hospital services. You say that you have reached 
your maximum out of pocket expense in August 2021. The Plan denied your request. The Plan says you were 
charged the correct cost sharing amount 
 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 your combined maximum out-of-pocket amount is $1,500, and this is the most 
you pay during the plan year for covered Medicare Part A and Part B services received from both in-network 
and out-of-network providers. The Plan contract also says that the amounts you pay for deductibles, 
copayments and coinsurance for covered services count toward this combined maximum out-of-pocket amount, 
(in addition, amounts you pay for some services do not count toward your combined maximum out-of-pocket 
amount. The Plan also says these services are marked with an asterisk in the Medical Benefits Chart.) The Plan 
contract also says if you have paid $1,500 for covered services, you will have 100% coverage and will not have 
any out-of-pocket costs for the rest of the plan year for Part A and Part B services. Your contract with the Plan 
also says that there is a 20% coinsurance which applies to for each covered Medicare-covered inpatient hospital 
care.  
 
You  have been asked to pay $521.31 in coinsurance, which is part of the 20% of the allowed amount for 
inpatient hospital services. The records shows that the $521.31 met your maximum out-of-pocket amount for 
the year. Inpatient hospital services fall within the inpatient hospital care benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $1,500 maximum out-of-pocket 
amount for the year and a 20% coinsurance which applies to inpatient hospital care. This cost sharing is a 
contractual obligation that had not been met at the time inpatient hospital services was received on August 22, 
2021, to August 26, 2021, however, was filled during the stay. Therefore, we decided that the Plan does not 
have to reduce the coinsurance for inpatient hospital services provided from August 22, 20201, to August 26, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthetic blocks of the genicular (knee) nerves. 
 
You asked the Plan to pre-approve the requested genicular nerve blocks. You say that this treatment should be 
allowed to assess whether denervation would be appropriate. The Plan denied your request. The Plan says this 
is considered experimental at this time. 
 
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 requested genicular nerve blocks. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a female with right knee pain from arthritis. She has tried 
Tylenol, ice, heat, elevation, and immobilization. The request is for bilateral diagnostic genicular nerve blocks. 
 
This procedure is considered experimental/ investigational at this time. There are ongoing clinical trials 
examining the role of these blocks for the treatment of knee osteoarthritis. Therefore, the request is considered 
not medically necessary or reasonable. 
 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 requested genicular nerve blocks have not been met. Therefore, we decided 
that the Plan does not have to pre-approve anesthetic blocks of the genicular (knee) nerves.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. The requested service cannot be recommended. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service December 
17, 2021. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 procedure code 70544 billed for date of service December 17, 
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 the enrollee has improved enough for admittance to 
an IRF. You say that physical therapy has been seeing the enrollee has feels as if acute rehabilitation is more 
beneficial for the enrollee. The Plan denied your request. The Plan says the guidelines for coverage have not 
been met. The Plan says that the enrollee's medical care is ongoing, and the amount of therapy is appropriate to 
meet her needs. The Plan says that with additional time under the care of her doctor, nurses, and therapists in 
the current facility, the enrollee may be ready to move to another setting in the future. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for infection of right artificial knee joint and had an above the knee amputation. The enrollees 
medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
There is not a reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from October 9, 2021, to October 10, 2021. 
 
 You asked the Plan to pay for the self-administered drugs. You say that the drugs that were given to you were 
administered intravenously. You say that you could not give them to yourself. You also say that the only thing 
you took by mouth was a small dose of liquid Potassium. The Plan denied your request. The Plan says the 
drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a 
Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under 
Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from October 9, 2021, to October 10, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time during a 
Public Health Emergency due to a respiratory-transmitted infectious disease (99072) provided on September 
17, 2021. 
 
You asked the Plan to pay for additional services. You say that the Plan has underpaid the services at an 
unconscionably low rate. You also say that you are requesting immediate payment to 30% of your billed charge 
for the referenced claim. The Plan denied your request. The Plan says the provider did not bill as required by 
Medicare coding regulations. 
 
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 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that the payment for CPT code 99072 is always bundled into the payment for 
another service. CPT code 99072 is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of additional supplies have not been met. Therefore, we decided that the Plan does 
not have to pay for additional supplies, materials, and clinical staff time during a Public Health Emergency due 
to a respiratory-transmitted infectious disease (99072) provided on September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a trial of a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve the SCS trial. You say that the enrollee has had back surgery which failed to 
address his pain, and he also had further conservative care after the surgery which has not helped. SCS trial is 
appropriate at this time. The Plan denied your request. The Plan says that this is not a late/last resort since the 
enrollee has not tried enough other treatments. There has not been a recent failure of conservative management. 
 
The Plan follows Medicare rules. Medicare rules say that SCS trials may be covered when certain criteria are 
met 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 the SCS trial. Our reviewer says that 
the requested trial of SCS is shown to be medically reasonable and necessary in this case. Our physician 
reviewer found the records show that the patient has post-laminectomy pain from surgery over one year ago. 
There is documentation of adequate conservative measures and also a psychiatric evaluation. The patient meets 
criteria for SCS trial. 
 
 
  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 SCS trial have been met. Therefore, we decided that the Plan has to pre-
approve a trial of a spinal cord stimulator (SCS).  
 
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 the drug testing rendered on September 28, 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 procedure code G0483 is not supported. 
 
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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation shows 
that 22 or more drug classes were not tested. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
drug testing rendered on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 5, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were told the copayment 
would be less because the procedure took place in a free-standing facility. The Plan denied your request. The 
Plan says the provider billed as an outpatient hospital. Therefore, the copayment for the services rendered at an 
outpatient hospital 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 a $85 
copayment for Basic Radiological Services in an Outpatient Hospital.  
 
  You have been asked to pay a $85 copayment for the ultrasound. The ultrasound falls within the Outpatient 
hospital 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 an ultrasound 
provided on May 5, 2021.