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

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 You asked the Plan to pre-approve continued SNF services. You say that the enrollee requires continued 
therapy. The Plan denied your request. The Plan says the enrollee does not require daily skilled services to 
restore or maintain function. 
 
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 services. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee requires daily skilled nursing services. The reviewer found that the enrollee 
may benefit from skilled therapy services on an as-needed basis. The reviewer also found that the enrollee does 
not require skilled therapy on a daily basis. 
 
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 services have not been met. The record indicates that the 
enrollee does not require daily skilled therapy services. Therefore, we decided that the Plan does not have to 
pre-approve continued skilled nursing facility (SNF) services.  
 
Please note: The Plan confirmed that outpatient physical therapy which can be provided by SNF. The approval, 
however would not cover room and board.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 17 home health aide visits. 
 
You asked the Plan to pre-approve 17 home health aide visits. 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 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 17 home health aide visits. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the home health aide services are reasonable and necessary to 
the treatment your illness or injury by the skilled professional staff. Provided records document a primary 
caregiver is already available around the clock to provide bathing, dressing, turning in bed, bathroom, meal 
prep and set up, medication management, grocery shopping, household chores and transportation for you. 
Records do not document the necessity of the additional requested home health aide service. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 17 home health aide visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 17 home health aide visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for SNF care. 
 
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 you do not have documented skilled nursing 
needs or skilled therapy needs.  Daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of your condition.  Your care needs, custodial and intermittent, can, as a practical matter, 
be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 16, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies (99072) provided on August 13, 2021. 
 
You asked the Plan to pay for supplies. You say that services were not available from network providers. The 
Plan denied your request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database 
(MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment 
for other services not specified. 
 
We looked at the file and Medicare rules. Code 99072 has a status indicator of B and is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for supplies (99072) provided on August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hydraulic patient lift with seater sling (E0630) for the 
enrollee. 
 
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met. 
 
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 lift. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that without this lift, the enrollee would be bed-confined. The 
criteria has not been met. 
 
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 lift have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a hydraulic patient lift with seater sling (E0630) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One knee injections. 
 
You asked the Plan to pre-approve the Synvisc One injections. You say that it is felt that this is appropriate 
treatment for the enrollee's condition. The Plan denied your request. The Plan says the prior injection only 
provided relief for one week. This is not considered effective treatment. As such, repeat injection is not 
supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the Synvisc One injections. Our 
reviewer says that the requested drug is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of knee pain. The record 
indicates that the pain is described as radicular in nature. The record does not indicate that X-ray findings 
support a diagnosis of osteoarthritis of the knee. The record indicates that previous injection with the requested 
product more than six months ago did not provide significant relief. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
elements of the coverage criteria are not satisfied.  
 
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 Synvisc One injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Synvisc One knee injections.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 units of needle electromyography (95870-59-26) provided 
on December 24, 2020. 
 
You asked the Plan to pay for needle electromyography. You say that these services were billed correctly and 
should be paid. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 95861 and 95870. This PTP edit has a modifier indicator of 
1, meaning modifiers associated with NCCI are allowed.  Code 95870 was billed with modifier 59, which can bypass this edit. However, the use of the modifier is not 
supported in this case. Modifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI 
PTP edit unless the proper criteria for the modifier are met. 
 
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 95861 
is a column II code to column I code 95870; however, 95861 was billed with a modifier.  
 
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 needle electromyography. Our reviewer says that these 
services are not supported as billed. Our reviewer found that the enrollee received neuromonitoring services on 
December 24, 2020. The provider reported CPT code 95870 with modifier 59 in addition to CPT code 95861. 
The documentation provided in this case does not support modifier 59 as a distinct and separate procedural 
service. Per the Centers for Medicare and Medicaid Services: CPT code 95870 is used for limited testing of 
specific muscles during an examination. This code should be used only when the muscles tested do not fit more 
appropriately under another CPT code. CPT code 95870 can be billed at one unit per extremity (one limb, arm 
or leg), when fewer than five muscles are examined. It can also be used for examining non-limb (axial) muscles 
(e.g., intercostal, abdominal wall, cervical and lumbar paraspinal muscles (unilateral or bilateral) regardless of 
the number of levels tested. However, it should not be billed when the paraspinal muscles corresponding to 
extremity are tested, and when the extremity codes 95860, 95861, 95863, or 95864 are reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the 
Plan does not have to pay for 2 units of needle electromyography (95870-59-26) provided on December 24, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation (ERFA) of 
varicose veins. 
 
You asked the Plan to pre-approve the ERFA procedure. You say that you cannot use compression stockings 
and elevation has not helped. You feel that this treatment is the only option at this time. The Plan denied your 
request. The Plan says there is no documentation that alternate types of compression stockings have been tried. 
Since conservative measures remain, ERFA is not appropriate at this time. 
 
The Plan follows Medicare rules. Medicare rules say that surgical treatment of varicose veins require a 
documented failure of conservative management as well as symptoms which meet the criteria listed in the 
Medicare rules section of this decision. 
 
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 ERFA procedure. Our reviewer says 
that the documentation does not support that the requested varicose vein treatment is reasonable and necessary. 
Our physician reviewer found the enrollee is an 86-year-old female with chronic peripheral venous 
insufficiency. The enrollee writes that her legs ache from time to time and are "lobster" red especially in the 
morning. The enrollee states that she cannot get elastic stockings on. She has just started working out 3 days a 
week, walking with walker. A Vascular Consultation Note on 11/18/21 documents that the enrollee had lower 
extremity pain and edema and has tried elevation but is not able to don compression stockings.  
 
The documentation does not support that a 3-month trial of conservative therapy has failed. The documentation 
in the case file, which includes photographs, does not support pain or burning in the extremity severe enough to 
impair mobility, recurrent episodes of superficial phlebitis, non-healing skin ulceration, bleeding from a 
varicosity, stasis dermatitis, and/or refractory dependent edema. 
 
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 ERFA procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous radiofrequency ablation (ERFA) of varicose veins.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87798, 87489, 87541, 
87581, 87640, and 87633) provided on August 12, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 87798, 
87489, 87541, 87581, 87640, and 87633, remain not supported. The place of service on the CMS-1500 form 
line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form 
indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in a skilled-nursing facility 
setting POS 31. Also, the laboratory results submitted indicate the specimen was collected on August 12, 2020, 
and received by the lab on August 13, 2020. Of note, the patient resides in New Jersey and the billing 
laboratory is located in Texas therefore the billed code cannot be verified. It is noted multiple attempts were 
made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to 
pay for the laboratory services (CPT code(s): 87798, 87489, 87541, 87581, 87640, and 87633) provided on 
August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (CPT code 99212) provided on November 1, 
2021. 
 
You asked the Plan to pay for the office visit. You say that you have utilized services from this provider in the 
past and you do not understand why the services were denied. The Plan denied your request. The Plan says the 
service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Medicare does not cover office visits performed by a chiropractor. 
Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99212) provided on 
November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided on September 
22, 2021. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the request for definitive urine drug testing of this number of drug classes is considered 
not medically reasonable and 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 pay for the drug testing. Our physician reviewer 
found the review indicates that the diagnosis is medication management of long term (current) drug therapy. 
The medical record sent by the provider shows a definitive UDT panel for multiple drug classes was performed 
but does not show screening test results which are positive or inconsistent with prescription medications, 
dosing schedules, or history and expected results. The review has determined that the medical records provided 
did not meet the requirements listed in the LCD for Medicare coverage. 
 
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing (CPT code G0483) provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chiropractic services provided from 
August 31, 2021, to November 24, 2021. 
 
You asked the Plan to waive the copayments for the chiropractic services. You say that you were informed that 
you could be reimbursed for the services. 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 $20 
copayment for each chiropractic visit.  
 
The file shows you had a total of 13 chiropractic visits from August 31, 2021, to November 24, 2021. You have 
been asked to pay a $20 copayment for each visit for the chiropractic services. The total for all visits is $260 
($20 copayment x 13 visits = $260). The chiropractic services fall within the Chiropractic 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 copayments for chiropractic services provided 
from August 31, 2021, to November 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 speech therapy visits. 
 
You asked the Plan to pre-approve 12 speech therapy visits. You say that the requested visits are necessary for 
the enrollee to be an effective communicator. The Plan denied your request. The Plan says the requested visits 
are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 12 speech therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program. The reviewer found that there is no 
documentation of a recent injury or decline in function. The reviewer also found that additional therapy 
services are not an appropriate duration and frequency for treatment of the enrollees medical condition and 
therefore are 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 12 speech therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 speech therapy visits.
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 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 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 at the current level of function, your rehabilitation can be safely provided at a lower intensity and alternate setting in a skilled nursing facility or in-home with services. Documentation does not 
support the necessity for admission to 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.