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

 
We decided that the Plan does not have to waive the copayment for laboratory services (80053, 85610, 85025) 
provided on October 25, 2021, and November 15, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. 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 $0-10 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $13.82 copayment for two laboratory services. 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 laboratory services (80053, 85610, 85025) provided on October 25, 2021, and 
November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the durable medical equipment services. You say that you would like 
reconsideration because the requested durable medical equipment is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 
durable medical equipment services to be provided 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 inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a left total 
hip arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan says 
there is no documentation provided to support the expectation you will require a greater than 2 midnight stay. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found you are approved for a left total hip arthroplasty. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530) and debridement (97597) 
provided on September 13, 2021, through October 22, 2021. 
 
You asked the Plan to pay for the therapeutic activities and debridement. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the services 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 97597 is debridement (eg, high pressure waterjet 
with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, 
devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound 
assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) 
surface area; first 20 sq cm or less. 
 
We find that CPT code 97597 is not supported in the medical record. Specifically, the documentation submitted 
does not indicate that debridement of an open wound was rendered on the billed date of service. 
 
Additionally, the record indicates that CPT code 97530 was billed by a nurse practitioner while the services 
were rendered by Physical and Occupational Therapists. The documentation submitted does not show that 
incident-to criteria have been met. Specifically, the documentation does not support that the billing nurse 
practitioner was present. 
 
Based on this information, we decided that Medicare rules for coverage of the therapeutic activities and 
debridement have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic 
activities (97530) and debridement (97597) provided on September 13, 2021, through October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing provided on December 1, 2021. 
 
You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration because you 
do not know why you were not reimbursed the full amount. The Plan denied your request. The Plan says you 
were reimbursed the Maximum Allowable Fee. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 testing have not been met. Specifically, the documentation submitted indicates that 
the Plan reimbursed you the Maximum Allowable Fee for the COVID-19 testing. The remaining balance is not 
the responsibility of the Plan. Therefore, we decided that the Plan does not have to pay for the COVID-19 
testing provided on December 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a disc tissue allograft (Via Disc). 
 
You asked the Plan to pre-approve implantation of a disc tissue allograft (Via Disc). The Plan denied your 
request. The Plan says implantation of a disc tissue allograft (Via Disc) is 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 implantation of a disc tissue allograft 
(Via Disc). Our reviewer says that the requested implantation of a disc tissue allograft (Via Disc) is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that this is an 
experimental/ investigational procedure. 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 implantation of a disc tissue allograft (Via Disc) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve implantation of a disc tissue allograft (Via Disc).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that medical necessity rules for SNF care have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee does not have documented skilled nursing needs but does have documented skilled therapy needs. The 
enrollee appears to be functioning below her baseline. The documentation does not establish that the enrollee 
has yet reached a new, lower, level of function. Daily skilled services are required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup and endodontic therapy (D2950, D3310) 
provided on December 1, 2021. 
 
You asked the Plan to pay for the core buildup and endodontic therapy. You say that you would like 
reconsideration because closing up the tooth after drilling was medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core buildup and endodontic therapy (D2950, D3310) provided on December 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the records provided support the 
need for inpatient psychiatric care. The Plan denied your request. The Plan says the enrollee does not have 
safety concerns that can only be treated in a hospital. 
 
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 care. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted 
to the acute inpatient psychiatric/detoxification hospitalization on February 18, 2022, with Schizoaffective 
Disorder, Bipolar Type, Posttraumatic Stress Disorder, Alcohol Use Disorder, Moderate and Cocaine Use 
Disorder, Moderate. Based upon review the records provided it was not expected this enrollee would improve 
in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted 
and no auditory or visual hallucinations. The enrollee did not show any abnormal behaviors or any symptoms 
which would require acute treatment. It did not appear medically necessary and reasonable to have 
psychiatric/detoxification care provided at the acute inpatient level of care rather than a lower level of care 
beyond the dates in question as she did not have dangerousness to self or others but was compliant with her 
treatment with encouragement. It did not appear that the services were reasonably expected to improve the 
patients condition or for the purpose of diagnosis beyond the date in question. I am unable to find an 
individualized treatment plan however the entire record is not present. It did appear that the records were 
supervised and evaluated by a physician. 
 
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 care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from November 19, 2021, through 
November 27, 2021. 
 
You asked the Plan to pay for SNF services. You say that the services the enrollee required and received are 
covered under the Medicare Act. The Plan denied your request. The Plan says October 29, 2021, to November 
18, 2021, is being approved as medically necessary. The Plan also says that November 19, 2021, to November 
27, 2021, is upheld as the member did not require skilled services. 
 
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 pay for SNF services. Our reviewer says that daily 
skilled services were no longer necessary. Our physician reviewer found that as of November 18, 2021, the 
member did not require any skilled nursing or rehab services on a daily basis. The members function was at or 
near her baseline level of function and she could have been discharged to a lower level of care for further 
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 pay for SNF services provided from November 19, 2021, through November 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia and nerve block procedures provided on May 
25, 2021, billed with codes 00563, 64420, and 64450. 
 
You asked the Plan to pay for the anesthesia and nerve blocks as billed. You say that this was billed correctly 
and should be paid. The Plan denied your request. The Plan says the billed codes are 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 00563 is anesthesia for procedures on heart, pericardial 
sac, and great vessels of chest; with pump oxygenator with hypothermic circulatory arrest. The definition of code 64420 is injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level. The definition of 
code 64450 is injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch. 
 
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 the anesthesia and nerve blocks as billed. Our reviewer says 
that the records provided do not support the billing of these codes. Our reviewer found the documentation only 
includes a procedure report. An anesthesia report was not found to support anesthesia services, nor any nerve 
blocks related to pain management. Therefore, these codes cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia and nerve blocks as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the anesthesia and nerve block procedures provided on May 25, 
2021, billed with codes 00563, 64420, and 64450.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 29, 2021, to January 1, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should have to pay 
this bill due to the quality of care that was received. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $300 
copayment per day for days 1-5 for an in-network inpatient hospital stay. The contract also says there is a $0 
copayment for additional days after day 5.  
 You have been asked to pay a total of $900, which is a $300 copayment per day for a three-day inpatient 
hospital stay ($300 copayment x 3 days = $900). There is no charge for additional days after day 5. There is 
also no charge for the day of discharge. An inpatient hospital stay falls within the Inpatient Hospital Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay 
provided from December 29, 2021, to January 1, 2022.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested direct 3D tomotherapy with image-guided 
radiation treatment (IGRT). 
 
You asked the Plan to pre-approve the requested tomotherapy with IGRT. You say that the Plan's alternate 
treatment is not available at this facility. This should be approved. The Plan denied your request. The Plan says 
the enrollee's condition would be best treated with complex isodose radiation treatment which is available at 
other network providers. 
 
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 tomotherapy with IGRT. 
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 male with bilateral femur metastases with prostate primary. The 
provider wishes to provide palliative radiation treatment to these lesions.  
 
Image guided radiotherapy (IGRT) is a means of using of using daily image guidance to help localize the target 
so as to minimize normal tissue dosing. IGRT allows accuracy of treatment delivery, so when generating a 
planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues 
exposed to radiation. IGRT images can be obtained prior to treatment on a daily basis (interfraction IGRT), 
and/or before and during radiation (intrafraction IGRT). Daily CT imaging or kv-kv imaging, to verify position 
prior to every fraction, is an integrated feature with the LINAC used for this patient as described in the case 
records.  
 
Generally, it is used when there is a need to escalate the dose, and or use tight margins to adequately treat the 
target while sparing surrounding normal tissue. With radiation for routine treatment of bone metastases, it is 
not standard to use IGRT (and no plausible rationale for the need of IGRT was offered in the case 
records). Usually, a port film is obtained prior to treatment (and perhaps a dry run simulation), but IGRT is not 
standard.  It seems as though IGRT is simply being used as routine practice, as there does not seem to be any 
exceptional circumstances with this patient necessitating the need for IGRT. Three-dimensional radiation is 
also not shown to be required, as it would be within accepted standards of care to use 2D radiation.  
 
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 tomotherapy with IGRT have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the requested direct 3D tomotherapy with image-guided 
radiation treatment (IGRT).
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 SNF care. You say that the requested SNF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical necessity rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you do not have documented skilled 
nursing needs nor skilled therapy needs. You are consistently ambulating more than 100 feet. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care.