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 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 this member does not have complex nursing and medical management 
needs requiring a resource intensive inpatient hospital setting. 
 
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 hypotension, 
pneumonia, and a urinary tract infection. 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: 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 the enrollee is at risk of not reaching his maximum 
rehab potential without the intensive therapy. The Plan denied your request. The Plan says that the services the 
enrollee needs can be provided safely in other settings. 
 
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 lumbar fractures and 
urinary tract infection. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visit and X-rays on May 27, 
2021. 
 
You asked the Plan to waive the copayments for specialist visit and x-rays. You say that you feel as though you 
should not be required to pay the cost sharing amount for services provided to you, as the provider did not 
indicate that anything could be done to treat your condition. The Plan denied your request. The Plan says $25 
for each specialist visit or telehealth service for Medicare-covered services and $10 for each Medicare-covered 
x-ray. 
 
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 $25 for 
each specialist visit or telehealth service for Medicare-covered services. Consultation, diagnosis, and treatment 
by a specialist. $10 copayment for each Medicare-covered x-ray. Covered services include but are not limited to: X-rays. There were 4 x-rays and 1 specialist visit, resulting in a 
total copayment amount of $65.  
 
You have been asked to pay a $25 copayment for specialist visit. Specialist visits falls within the 
Physician/Practitioner services, including doctors office visits benefit category. You have a $25 copayment for 
each specialist visit or telehealth service for Medicare-covered services. You have been asked to pay a $10 
copayment for x-rays. X-rays falls within the Outpatient diagnostic tests and therapeutic services and supplies 
benefit category. You have a $10 copayment for each Medicare-covered x-ray. The allowed amount on this 
claim is $65. 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 specialist visit and X-rays on May 27, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia provided on November 27, 2019. 
 
You asked the Plan to pay for the anesthesia. You say that the service should be covered. The Plan denied your 
request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesia was not filed until December 17, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the anesthesia provided on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays you received from a chiropractor on November 19, 
2021. 
 
You asked the Plan to pay for the x-rays. You say that it is better for your if the chiropractor knows precisely 
where to use the activator, so x-rays were needed. These x-rays protect the chiropractor and the patient and 
may even shorten the amount of time care is needed. The Plan denied your request. The Plan says x-rays from a 
chiropractor are not covered. 
 
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. Therefore, we decided that 
the Plan does not have to pay for x-rays you received from a chiropractor on November 19, 2021.  
 
Please note: the Plan originally included a dispute regarding a copayment for chiropractic services in the appeal 
case file it sent to us.  However, your appeal letter does not appear to be disputing this copayment.  As a result, 
this decision is limited to the issue of the x-rays.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
August 6, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were provided to the enrollee 
in good faith. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 20552 provided on December 6, 
2021. 
 
You asked the Plan to pay for the injection services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says an incorrect code was billed based on the 
services that were rendered. 
 
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 20552 is injection(s); single or multiple trigger point(s), 1 
or 2 muscle(s). 
 
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 injection services. Our reviewer says that the 
documentation does not support the payment of CPT code 20552 as billed. Our reviewer found the enrollee is a 
68-year-old male with a history of a right 5th trigger finger with contraction at the proximal interphalangeal 
(PIP) and distal interphalangeal (DIP) joints. He received a trigger finger injection at both joints to relieve the 
contracture. The correct CPT code for a trigger finger injection (injection administered to the tendon sheath) is 
20550. The review indicates that the medical records do not indicate that any trigger point injections (CPT code 
20552) were provided on the date of service.  
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 injection services have not been met. Therefore, we decided that the Plan 
does not have to pay for the injection services coded 20552 provided on December 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional computed tomography scan (74177) provided 
on April 29, 2021. 
 
You asked the Plan to pay for an additional computed tomography scan. You say that the enrollee had multiple 
exams. The Plan denied your request. The Plan says this was previously billed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional unit of CPT code 74177 are not supported in the medical record. The medical record 
only supports one unit of CPT code 74177, which was previously billed and paid. Based on this information, 
we decided that Medicare rules for coverage of an additional computed tomography scan have not been met. 
Therefore, we decided that the Plan does not have to pay for an additional computed tomography scan (74177) 
provided on April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this is safe and effective and the enrollee has failed 
conservative treatment. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because Intracept 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental/investigational procedure the role of which in the management of low 
back pain is still being considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (00350) provided on November 10, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the provider was certified to provide the 
services at issue on the date of service. The Plan denied your request. The Plan says that rules for payment have 
not been met. 
 
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. The Plan has not provided documentation to support its denial rationale nor 
explained why an anesthetist would not have been able to provide the services at issue. It is the Plan's 
responsibility to substantiate its denial. In this case, the Plan has not substantiated its denial, so we must find in 
your favor. Therefore, we decided that the Plan has to pay for anesthesia services (00350) provided on 
November 10, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on July 12, 2021. 
 
You asked the Plan to pay for an outpatient visit. The Plan denied your request. The Plan says you must receive 
your care from a network provider. Three exceptions are if you visit an emergency or urgent care facility, if 
you need medical care Medicare covers that is not available from network providers, or for kidney dialysis 
services received while temporarily outside the Plans service area. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services.  
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for outpatient visit provided on July 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided to the enrollee on January 
19, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that that hospital bundling rules exclude payment to 
independent suppliers of ambulance services for beneficiaries in a hospital inpatient stay.  
 
We looked at the file and Medicare rules. The ambulance services in this case were provided during an 
inpatient hospital stay. Ambulance services are not separately payable when provided during an inpatient stay. 
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 the ambulance services provided to the enrollee on 
January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable cardiac loop recorder (33285). 
 
You asked the Plan to pre-approve the cardiac loop recorder. You say that 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. The Plan 
denied your request. The Plan says the implantable loop recorder is not medically necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the cardiac loop recorder. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no history of an ambulatory ECG monitor having been performed to assess a 
possible arrhythmic etiology of syncope. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR in this patients clinical management. 
 
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 cardiac loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the implantable cardiac loop recorder (33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this is an experimental/investigational 
procedure. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this 43-year-old male is being treated for low back and right knee pain. He 
presented via telehealth with fairly significant lumbar degenerative disc changes at L5-S1 and L1-2. There are 
Modic changes at L5-S1 and severe narrowing of the neuroforamina at L5. His symptoms are all axial. 
 
Overall, 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. In this case, there were/are multiple plausible pathologic sources of significant pain generation. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the requested Intracept intraosseous nerve ablation at L5-S1, in this case, 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital admission provided on February 10, 20212, 
to February 15, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the services should be covered. The Plan denied 
your request. The Plan says that the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not include medical records to support the plan's 
denial. The file indicates that the plan received records but did not forward them to us. Therefore, we decided 
that the Plan has to pay for the acute inpatient hospital admission provided on February 10, 20212, to February 
15, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on February 3, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you were choking. You say that your partner 
called an ambulance. You say that the item was dislodged before the ambulance arrived. You also say that you 
should not be responsible for this charge. The Plan denied your request. The Plan says since there was no 
transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on February 3, 2022.