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

 
We decided that the Plan does not have to waive the copayments for the radiology services provided from 
October 28, 2021, November 4, 2021, November 9, 2021, November 12, 2021, November 16, 2021, November 
18, 2021, November 23, 2021, December 6, 2021, December 8, 2021, and December 20, 2021 
 
You asked the Plan to waive the copayments for the radiology services. You say that the technician only turns 
the machine on, and you never see the physician. The Plan denied your request. The Plan says the proper 
copayment was applied for the services that was billed with the office code that includes treatment by a 
specialist. 
  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 $35 
copayment for Physician specialist services including Consultation, diagnosis, and treatment by a specialist. 
There was a total of 10 visits with a total copayment amount of $350 (10 visits x $35 copayment each visit). 
 
You have been asked to pay a $350 copayment for the radiology services. The radiology services fall within the 
Physician/Practitioner services, including doctors office visits 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 the radiology services provided from October 28, 2021, November 4, 2021, 
November 9, 2021, November 12, 2021, November 16, 2021, November 18, 2021, November 23, 2021, 
December 6, 2021, December 8, 2021, and December 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injection services. 
 
You asked the Plan to pre-approve sacroiliac joint injection services. You say that the clinical notes and 
physical therapy notes support the need for the requested injection services. You say that the enrollee has been 
waiting months for this injection to treat severe back pain. The Plan denied your request. The Plan says the 
records do not show that the enrollee has tried physical therapy for six weeks. The Plan says that the office 
notes from the enrollee's doctor must show that the pain is coming from the sacroiliac joint. 
 
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 sacroiliac joint injection services. Our 
reviewer says that sacroiliac joint injection services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation indicates a history of lumbar radiculopathy and 
sacroiliac pain however the documentation does not reveal that the enrollee has completed physical therapy for 
this condition yet.  
 
 The requested sacroiliac injections at this time, without completion of physical therapy, would not be medically 
necessary per the accepted standards of medical practice for the diagnosis or treatment of the enrollee's 
condition. sacroiliac injections would not be required to improve the function of a malformed body member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve sacroiliac joint injection services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99310) provided on February 24, 2021. 
 
You asked the Plan to pay for nursing care. You say that this service was billed correctly. The Plan denied your 
request. The Plan says the Place of Service (POS) code used on this claim is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that POS code 31 (skilled nursing facility) is not supported in the record. Specifically, the location 
where these nursing services took place is classified as a long-term nursing facility, which is better described 
with POS code 32. Based on this information, we decided that Medicare rules for coverage of nursing care have not been met. Therefore, we decided that the Plan does not have to pay for nursing facility care (99310) 
provided on February 24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service February 21, 
2022, to February 22, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that this claim was underpaid. The Plan denied 
your request. The Plan says procedure code 99285 was not supported in the medical record, so the claim was 
downgraded to pay at the rate for code 99284. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for procedure code 99285. Our reviewer says that procedure 
code 99285 is not supported in the medical record. Our reviewer found the patient is a 65-year-old male with a 
past medical history of hypertension who presented to the emergency department (ED) after a near syncopal 
episode while driving. He also complained of a mild headache after the episode as well as nausea and 
weakness. On exam, the vital signs were stable. A computed tomography and lab evaluation were 
unremarkable. The patient was admitted for further evaluation and treatment. The submitted level of CPT code 
99285 is not appropriate in this case. The patient presented with dizziness and near syncope. The vital signs 
and evaluation were unremarkable. This was not consistent with a threat to life or physiologic function. 
Although it was a moderate to highly severe presentation, the medical decision making would not be 
considered highly complex. The appropriate level of the evaluation and management (EM) claim would be 
CPT code 99284. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 billed for date of service February 21, 2022, to February 22, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) provided 
to the enrollee on November 11, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the criteria is not met for CPT 99285. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. 
 Our reviewer found the review indicates that the criteria for CPT 99285 was not met, specifically - Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic 
function was not met. The review has determined that the records did not support the level of care represented 
by CPT 99285. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) provided to the enrollee on November 11, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services (T1019). 
 
You asked the Plan to pre-approve personal care services. You say that the enrollee would benefit from a 
personal home helper to assist them with their activities of daily living (ADLs). The Plan denied your request. 
The Plan says the claim denied correctly. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of personal care services (T1019) have 
been met. Specifically, the file does not include medical records showing that the requested services are 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve personal care services 
(T1019).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
first two vertebral bodies for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this procedure is considered not to be medically necessary due to the lack of 
clinical evidence that it has an impact on improved health outcomes. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that overall, the documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. The documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. In this case, there 
were/are multiple plausible pathologic sources of significant pain generation. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for Intracept intraosseous basivertebral nerve ablation at L4-5 is 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve, first two vertebral bodies for the 
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you do not have any transportation 
for your dialysis three time a week. The Plan denied your request. The Plan says you have exhausted the 
established benefit or 24 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergency ambulance transportation (A0428) and ground 
mileage (A0425) provided on February 16, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee was discharged from the hospital and admitted to the nursing and rehabilitation facility on the same 
date of service. You also say that the transport should be payable by the insurance directly. The Plan denied 
your request. The Plan says that the enrollee was in an inpatient hospital status on the date of service reported. 
 
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. We find that the documentation supports that the enrollee was discharged from 
inpatient status prior to this transportation. Therefore, we decided that the Plan has to pay for the non-
emergency ambulance transportation (A0428) and ground mileage (A0425) provided on February 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
December 2, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the documentation does not support the items billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Review of the file shows that the shipping and delivery 
date to not match the date of service billed. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitor (CGM) supplies provided on December 2, 2021.
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 the service is not medically necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs or documented skilled therapy needs. The enrollee is ambulating more than 
100 feet and tending to ADLs with minimal supervision. Daily skilled services are not shown to be required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an osteogenesis stimulator on February 18, 
2022. 
 
You asked the Plan to waive the copayment for an osteogenesis stimulator. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the cost share applied is correct, per the 
member's EOC, there is a 20% coinsurance for durable medical equipment (DME) that totals $350.01 or more 
in cost. 
 
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% 
coinsurance for an osteogenesis stimulator. The total allowed amount of the osteogenesis stimulator is 
$3,808.02, resulting in a coinsurance amount of $761.60. 
 
 
 
 You have been asked to pay a 20% coinsurance for an osteogenesis stimulator. an osteogenesis stimulator falls 
within the Durable medical equipment (DME) and related 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 an osteogenesis stimulator on February 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health physical therapy visits. 
 
You asked the Plan to pre-approve 2 home health physical therapy 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 2 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care. As such, the requested, ongoing, home health physical therapy services 
are 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 2 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 2 home health physical therapy 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs or documented skilled therapy needs. Daily skilled services are not shown to be required 
to establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the strapping or application of Unna boots 
for wound treatment provided from March 10, 2022, to April 7, 2022. 
 
You asked the Plan to waive the copayment for wound care. You say that you do not agree with the assessed 
copayment. The Plan denied your request. The Plan says the copayment 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 $250 
copayment for outpatient surgery or procedures in an outpatient hospital setting.  
 
You have been asked to pay a total copayment of $725.75 for wound care. Wound care falls within the 
outpatient hospital services benefit category. The Plan only allowed the provider to bill $145.15 for each visit, 
which is less than the contractually required $250 copayment listed in the EOC. This means you are only 
responsible for the lesser amount of $145.15 per visit, which means that you have been asked to pay the correct 
amount based on your contract with the Plan ($145.15  7 visits = $725.75).  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 strapping or application of Unna boots for 
wound treatment provided from March 10, 2022, to April 7, 2022.