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

 
We decided that the Plan does not have to pay the copayment for the ambulance transportation provided on 
December 1, 2021. 
 
You asked the Plan to pay the copayment for the ambulance transportation. You say that you were told that this 
service would be fully covered. The Plan denied your request. The Plan says the service was fully covered, and 
the proper copayment 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 $225 
copayment for each one-way Medicare-covered ground trip.  
 
  You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 pay the copayment for the 
ambulance transportation provided on December 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ultrasonic Guidance provided on July 29, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Ultrasonic Guidance. You say that you are requesting for the payment and 
seeking a review. The Plan denied your request. The Plan says non-urgent services are not authorized because 
provider is a non-network provider with the members health plan. 
 
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 Ultrasonic Guidance provided on July 29, 2021 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99203) provided on 
February 25, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you received a bill from 
your specialist office visit, and you believe that for visiting your specialist, it is covered in full. The Plan denied 
your request. The Plan says you were 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 $30 
copayment for a specialist doctor visit in office or telehealth.  
 
You have been asked to pay a $30 copayment for a specialist office visit. 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 a specialist office visit (99203) provided on February 25, 2021.
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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. There is no 
documentation that daily skilled services are required. Provided records do not document a significant decline 
in the enrollees functional status compared to his recent baseline to necessitate daily inpatient skilled therapy 
services. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the long-term care facility on a part time basis appear 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 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: 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 you need IRF care. The Plan denied your request. 
The Plan says you do not meet the Medicare criteria for admission to an IRF. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary 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. 
 
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 waive the deductible for an office visit provided on October 25, 
2021. 
 
You asked the Plan to waive the deductible for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the deductible 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 $600 deductible which applies to Physician/Practitioner Services, 
Including Doctors Office Visits.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $600 deductible which applies to Physician/Practitioner 
Services, Including Doctors Office Visits. This cost sharing is a contractual obligation that had not been met at 
the time the office visit was received on October 25, 2021. Therefore, we decided that the Plan does not have to 
waive the deductible for an office visit provided on October 25, 2021.  
 
Since the $600 deductible was met, you have also been asked to pay a $2.99 copayment. 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.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
December 4, 2020. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you did not have any treatment only 
had your blood drawn at the hospital before being transferred. You also say that all copayments related to 
COVID-19 were waived. 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 $90 
copayment for an in-network emergency room visit.  
 
 You confirmed that you had your blood drawn and were seen in the emergency room on December 4, 2020. 
Even though, you say you did not received treatment and were transferred the cost sharing still applies. The 
record also shows no COVID-19 diagnosis were included on this claim. You have been asked to pay a $90 
copayment for an ER visit. An ER 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 waive the copayment for an emergency room (ER) visit provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography interpretation (95861) provided 
on April 26, 2021. 
 
You asked the Plan to pay for the needle electromyography interpretation (95861). You say that the surgeon 
requested these services for the safety of the patient and intraoperative neuromonitoring is a medically 
necessary procedure. You say that the monitoring was to ensure the surgery went smoothly and the claim 
should be reprocessed at the in-network level. The Plan denied your request. The Plan says the submitted 
documentation supports 1 unit of 95861-26, which was previously approved/paid. There is no additional 
documentation supporting an additional study which was billed and remains denied. 
 
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 95861 is needle electromyography; 2 extremities with or 
without related paraspinal areas. 
 
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 needle electromyography interpretation (95861). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that an additional unit of service cannot be verified. There are two copies of a technical report 
and the same providers for each report. Therefore, 2 units of service for this procedure could not be validated. 
 
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 needle electromyography interpretation (95861) have not been met. 
Therefore, we decided that the Plan does not have to pay for the needle electromyography interpretation 
(95861) provided on April 26, 2021.
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 an IRF would be a better fit for the enrollee's current 
condition. The Plan denied your request. The Plan says the enrollee does not meet criteria for an IRF 
admission. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty group 3 power wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says you 
do not meet the requirement for the wheelchair. 
 
The Plan must follow Medicare rules. The rules say that power wheelchairs are only covered under certain 
medical indications.  
 
We looked at the file and the rules. The requested wheelchair is for those with a weight capacity from 451-600 
pounds. The file does not show that your weight falls within these parameters. Based on this information, we 
decided at the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy-duty group 3 power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrocentesis (20610) provided on December 15, 2020. 
 
You asked the Plan to pay for the arthrocentesis (20610). You say that additional information supports 20610. 
The Plan denied your request. The Plan says the records do not support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20610 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. 
 
 
  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 arthrocentesis (20610). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the procedure should be billed with a bilateral modifier. Therefore, an additional unit is not supported by the 
medical record. 
 
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 arthrocentesis (20610) have not been met. Therefore, we decided that the 
Plan does not have to pay for the arthrocentesis (20610) provided on December 15, 2020.
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 you had a stroke in 2019 and need physical and 
occupational therapy. The stroke affected your left side, and you did therapy in the hospital. You said you are 
now losing muscle mass/having atrophy and getting weaker. You feel you would benefit from intense physical 
therapy because you are young and currently bed ridden, and it is very difficult for you to get up. You said that 
the more you stay in bed, the weaker you get. You want to be able to see your daughter graduate and be a part 
of her life with things such as prom dress shopping and visiting colleges. You feel that you are missing out on 
these things and are ready to do the work that is necessary to get you up and moving again. You said that you 
would benefit tremendously from intense therapy, and they could help you to walk and move again. The Plan 
denied your request. The Plan says IRF care is not medically necessary. 
 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical 
history of stroke in 2019 and are living at home with weakness and progressive decline in ability to 
ambulate.  Your medical problems are stable and 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap (15733) 
provided on April 9, 2021. 
 
You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap (15733). You say that after a 
coding review it was found that the correct services were billed. You say that the medical records support the 
services were medically necessary and should be processed for payment. The Plan denied your request. The 
Plan says procedure code 15733 is not supported by the medical records submitted. 
 
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 muscle, myocutaneous, or fasciocutaneous flap; head and 
neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, 
levator scapulae). 
 
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 muscle, myocutaneous, or fasciocutaneous flap (15733). 
Our reviewer says that the documentation does not support that a muscle, myocutaneous, or fasciocutaneous 
flap was obtained from the head and neck with named vascular pedicle. Our reviewer found that the surgeon 
performed bilateral cheek advancement flaps, with excision of Burow's triangles. 
 
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 muscle, myocutaneous, or fasciocutaneous flap (15733) have not been met. 
Therefore, we decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap 
(15733) provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hereditary genetic cardiac test provided to the enrollee on 
August 17, 2021. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says the provider does not have any documentation on how the test results will affect the patient outcome 
or change the treatment plan. 
 
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 test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
provided test appears to be a screening test; Medicare does not cover screening tests unless it is on a specific 
Medicare covered list. Medicare covers lipid testing for evaluation of atherosclerotic cardiovascular disease 
once every five years; the hereditary genetic cardiac test is not listed as a covered screening test by Medicare 
for screening for cardiovascular disease. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for a hereditary genetic cardiac test provided to the enrollee on August 17, 2021.