Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you do not have complex medical or intensive rehabilitation needs 
requiring supervision by a rehabilitation physician and an intensive and coordinated interdisciplinary team in a 
resource intensive inpatient hospital environment. 
 
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have 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 you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on November 22, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on  
November 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visits and an endoscopy (99203, 
31233) provided on January 12, 2022. 
 
You asked the Plan to waive the deductible for the office visits and endoscopy. 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. Your 
contract with the Plan says that there is a $150 deductible which applies to Outpatient surgery, including 
services provided at hospital facilities and ambulatory surgical centers and Physician/Practitioner services, 
including doctor's office visits.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
surgery, including services provided at hospital facilities and ambulatory surgical centers and 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $150 deductible which applies to Outpatient surgery, including 
services provided at hospital facilities and ambulatory surgical centers and Physician/Practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
the office visits and endoscopy was received on January 12, 2022. Therefore, we decided that the Plan does not 
have to waive the deductible for office visits and an endoscopy (99203, 31233) provided on January 12, 2022.  
 
Since the deductible was met, you have also been asked to pay a $100 copayment for an Endoscopy (31233) 
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 Endoscopy (31233) provided on January 12, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay the copayment for an emergency room visit provided on 
November 13, 2021. 
 
You asked the Plan to pay the copayment for the emergency room visit. You say that you were told there would 
not be a copayment for each visit to the emergency room and you would like the claim reprocessed and paid. 
The Plan denied your request. The Plan says the proper copayment was applied for the service that was 
rendered. 
 
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 $120 
copayment for Emergency Services at an Emergency Room.  
 
  You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency 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 pay the copayment for an emergency 
room visit provided on November 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider on September 20, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
 
 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cell enumeration using immunologic selection and 
identification in fluid specimen (86153) provided on November 29, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached medical records 
and reconsider the claim for payment. This service was medically necessary for the enrollee to have done as 
medical records support. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 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 cell enumeration using immunologic selection and 
identification in fluid specimen (86153) provided on November 29, 2021 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 rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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.  
 The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive 
heart failure and respiratory failure. 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. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for right-sided radiofrequency ablation (RFA) of the sacroiliac 
(SI) joint nerves provided on October 13, 2021. 
 
You asked the Plan to pay for the SI joint RFA procedure. You say that it is felt that this should be paid as it is 
helpful in reducing the enrollee's pain. The Plan denied your request. The Plan says this is not proven to be 
effective. 
 
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 pay for the SI joint 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 65-year-old male with chronic low back pain and sacroiliitis. He has 
positive Physical exam findings supporting this diagnosis. He has tried conservative therapy including Physical 
therapy and a Home Exercise program.  
 
This is considered experimental/ investigational because of the wide variation in efficacy reported in the 
literature. Therefore, the request was considered 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 SI joint RFA procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for right-sided radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves 
provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhythm electrocardiogram (EKG) report rendered on 
October 29, 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 93042 is not separately payable. 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 93042 (rhythm EKG report) and 21310 (closed treatment 
of nasal bone fracture without manipulation). Code 93042 is a column II code with a modifier indicator of 1 
when billed with column I code 21310. Code 93042 was not billed with an appropriate modifier to allow for 
separate payment. Therefore, we decided that the Plan does not have to pay for the rhythm electrocardiogram 
(EKG) report rendered on October 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on July 16, 2021, 
and the CT scan provided on September 16, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound and CT scan. You say that that you should not 
have to pay $125 for a 10-minute test. The Plan denied your request. The Plan says the copayment 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 $125 
copayment for an ultrasound and CT scan.  
 
You have been asked to pay a total of $250 ($125 copayment for an ultrasound and a $125 copayment for the 
CT scan). The ultrasound and CT scan fall within the Outpatient diagnostic tests and therapeutic services and 
supplies 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 the ultrasound and CT scan 
provided on July 16, 2021, and September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertical shock reducing pylon feature including the 
Pro Flex Foot and the Unity Foot. 
 
You asked the Plan to pre-approve the requested prosthetic equipment. You say that this equipment is 
medically necessary. The Plan denied your request. The Plan says the requested equipment exceed the 
enrollee's needs. 
 
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 prosthetic equipment. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a review of the ProFlex indicates that this is a compact energy-storing foot 
that offers rotational shock absorption designed to reduce shear forces on the residual limb. The ProFlex is 
helpful for amputees with longer limbs. A review of the ProFlex also states that amputees with a longer limb 
can enjoy greater comfort in a wide range of activities. The anatomical foot cover features a steady grip sole for 
barefoot stability on wet or slick surfaces, and a sandal clamping toe for a range of footwear including flip 
flops. The documentation by the treatment medical provider does not support that the patient has a longer limb 
that requires a specific vertical shock reducing pylon feature. Additionally, the requested Pro Flex has deluxe 
features such as a sandal clamping toe which exceed the patient's medical need. The Proflex was to be used 
with the L5781 vacuum pump. As the Proflex is not medically necessary the L5781 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 requested prosthetic equipment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the vertical shock reducing pylon feature including the Pro Flex Foot 
and the Unity Foot.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
27, 2021. We also decided that the Plan does not have to waive the coinsurance for an ankle orthosis (brace) 
provided on October 27, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the urgent care visit and ankle brace. You say 
that you feel you received improper treatment and the provider should not be paid. The Plan denied your 
request. The Plan says the correct copayment and coinsurance was applied. 
 
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 each urgent care visit. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each orthosis item, 
including braces. 
 
You have been asked to pay a $30 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed Services benefit category. You have also been asked to pay $15 for the ankle brace, which is 
20% of the allowed amount ($75 allowed amount x 20% coinsurance = $15). The ankle brace falls within the 
Prosthetic Devices and Related Supplies benefit category. The total for your visit is $45. 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 urgent care visit provided on October 27, 2021. We also decided 
that the Plan does not have to waive the coinsurance for an ankle orthosis (brace) provided on October 27, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An Office Visit provided on May 13, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for An Office Visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for An Office Visit provided on May 13, 2021 by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. After two weeks of 
daily inpatient skilled therapy services, you made minimal improvement in functional status. Predictable 
improvement in function within a reasonable timeframe does not appear to be achievable at this point and part-
time therapy services now appear indicated. You do not require the services on an inpatient basis, only in a 
skilled nursing facility setting. Records do not document that services in the home with home health care or in 
a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88342) provided October 27, 2021. 
 You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the code billed has a bundled relationship with another code 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, we have confirmed that code 88342 
has a bundled relationship with code88189. 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 lab services (88342) provided October 27, 2021.