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

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 5, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8. The records 
show that the services were not performed in the inpatient setting. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on February 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62324-59 billed for date of service October 
20, 2021. 
 
You asked the Plan to pay for procedure code 62324-59. You say that modifier -59 was billed appropriately 
and separate payment should be made. The Plan denied your request. The Plan says the modifier -59 billed 
with procedure code 62324 is not supported. Therefore, separate payment for this code cannot be made because 
payment for this code is bundled into payment for code 00500. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 62324-59 Our reviewer says 
that the use of modifier -59 in this case is not supported. Our physician reviewer found the procedure report 
does not include documentation to support this procedure as separate from the anesthesia service provided, and 
therefore this service cannot be verified. The operative report documents "Anesthesia; general and epidural".  Post operative pain management is separately covered when certain criteria are met. In this case, 
documentation does not support this procedure as separately from anesthesia services provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 62324-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 62324-59 billed for date of service October 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued skilled nursing facility (SNF) admission and 
services provided January 1, 2022, through January 6, 2022. 
 You asked the Plan to pay for the continued SNF care. You say that these services are coverable. The Plan 
denied your request. The Plan says by January 1, 2022, clinically, the enrollee's condition no longer required 
daily skilled services at a SNF level of 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 pay for the continued SNF care. Our reviewer says 
that daily skilled services are not necessary from January 1, 2022, through January 6, 2022. Our physician 
reviewer found that the enrollee did not have daily skilled nursing needs that required the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting for the dates of service in question. 
 
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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pay for the continued skilled nursing facility (SNF) admission and services provided January 
1, 2022, through January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a bone graft at time of implant placement (D6104) for tooth #12 
and #13. 
 
You asked the Plan to pre-approve a bone graft. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says that dental records and x-ray(s) support bone graft at time of implant 
placement (D6104) for teeth #'s 12 and 13, are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a bone graft 
when the services are medically necessary and reasonable. 
 
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 a bone graft. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the documentation provided meets the criteria for 
coverage for bone graft at time of implant placement in areas #12 and 13. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a bone graft have been met. Therefore, we decided that the Plan has to pre-
approve a bone graft at time of implant placement (D6104) for tooth #12 and #13.  
 
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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency services that was provided December 28, 2021. 
 
You asked the Plan to pay for the emergency services. You say that the provider is enrolled with Medicare and 
the Medicare provider enrollment letter is attached for review. Please review this claim and reprocess for 
payment promptly and accordingly. The Plan denied your request. The Plan says that Medicare does not cover 
services that are not performed by a Medicare certified provider. 
 
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. There were no medical records included in the case file. The records show that 
the facility provided their temporary Medicare hospital enrollment letter which is dated before this date of 
service. The Plan has not provided any documentation to substantiate their reason to continue to deny.    
Therefore, we decided that the Plan has to pay for the emergency services that was provided December 28, 
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: 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 records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. Although records 
document you are very limited functionally, provided records do not document a significant decline in your 
functional status compared to your recent baseline to necessitate daily inpatient skilled therapy services and 
therapy notes document that your rehabilitation potential is poor. You do not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the home 
with home health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a medically necessary 
treatment. The Plan denied your request. The Plan says there is not sufficient evidence to support this 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Superion spacer is experimental for back pain. More research is needed. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be stable and improving and should only require short-term 
additional acute care services that can be safely completed at the current facility until more appropriate for a 
lower level of care. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be stable and improving and should only require short-term additional 
acute care services that can be safely completed at the current facility until more appropriate for a lower level 
of care. There are no services at the LTACH that you require that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
Completion of treatment at the current facility is recommended. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 24, 
2021, to May 14, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee is a 70-year-old female who presented to the emergency department 
(ED) with nausea, vomiting, and inability to tolerate by mouth. She was noted to have elevated transaminases. 
Her symptoms were found to be related to inappropriately using pyrazinamide at home prior to the ED visit. 
RIPE therapy was held and the enrollee's symptoms improved. Based on the clinical presentation and history, it 
was not expected that the enrollee would require hospital services that would likely cross 2 midnights. Lower 
level of care would have been more appropriate for ongoing workup and diet advancement as she was stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from April 24, 2021, to May 14, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (CPT code J1439). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s) Infed (iron 
dextran) and Venofer (iron sucrose). The Plan state there is no indication the Plan's preferred drug(s) would 
likely be: less effective, and/or cause adverse effects for the enrollee. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the provider requested Injectafer to treat iron deficiency anemia. The Plan requires a trial of drug Infed 
(iron dextran) and Venofer (iron sucrose), before they will approve the requested drug. In this case, the enrollee 
has not tried and failed the required drug(s). There is no documentation provided indicating that the plans 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer (CPT code J1439).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 6, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that this provider is in-network and this service was 
necessary. The Plan denied your request. The Plan says Medicare does not cover eye refractions. Your Plan offers supplemental coverage for routine vision services; however, the rules for coverage of this service have 
not been met. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury. However, the Plan offers a routine vision and eyewear benefit that 
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eye 
refractions when they are provided as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The documentation shows that on the date in question you received a 
medical (non-routine) eye exam which included diagnostic imaging. Based on this information, we decided that 
the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does 
not have to pay for the eye refraction (92015) provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Foundation Pain Index testing provided on April 13, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document that the Foundation Pain Index testing meets Medicare criteria for medically reasonable and necessary as defined by Social Security Act, Section 1862 (a)1(A) and the 42 
CFR Section 411.15(k). Long term clinical validity and clinical usefulness of the testing has not been 
demonstrated in the peer-reviewed medical literature. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Foundation Pain Index testing provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation (85060) provided on February 
1, 2022. 
 
You asked the Plan to pay for the blood smear interpretation. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
billed with an appropriate place of service per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients. 
 
We looked at the file and Medicare rules. The claim indicates that this service was billed with place of service 
22 indicating hospital outpatient. No payment is made for code 85060 for hospital outpatients. Based on this information, we decided that Medicare rules for coverage of the blood smear interpretation have not been met. 
Therefore, we decided that the Plan does not have to pay for the blood smear interpretation (85060) provided 
on February 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. Although records 
document you are very limited functionally, provided records do not document a significant decline in your 
functional status compared to your recent baseline (nor have you shown benefit with therapies provided thus 
far) to necessitate further daily inpatient skilled therapy services. Part time therapy services now appear 
indicated. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. 
Records do not document that services in the home with home health care or in a long-term care facility on a 
part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.