Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on knee procedures (20610, 
27487) provided on September 4, 2020. 
 
You asked the Plan to pay for surgical assistant services. You say that these services should be covered. The 
Plan denied your request. The Plan says these services were not provided by an eligible provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on knee 
procedures (20610, 27487) provided on September 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another 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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for cervical spine surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this 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 admission to an inpatient rehabilitation facility (IRF).
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 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing 
or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical 
matter you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
14, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 14, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical trays (A4550) provided on September 28, 2021. 
 
You asked the Plan to pay for the surgical trays (A4550). You say that this service was approved, and the 
approval was based on medical necessity. You say that the claim should be reviewed and reprocessed. The Plan 
denied your request. The Plan says the claim has been reprocessed to pay for CPT code 62327. CPT code 
A4550 remains denied as bundled services are not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  We find that CPT code A4550 is not supported in the medical record. Specifically, CPT code A4550 has a 
status indicator of B. This means that CPT code A4550 is considered bundled and not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the surgical trays (A4550) have not 
been met. Therefore, we decided that the Plan does not have to pay for the surgical trays (A4550) provided on 
September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that this service is payable under Medicare 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
The file shows that the enrollee received the AlloSure Kidney test. We looked at the file and Medicare rules. In 
this case, the claim was billed with the laboratory POS code. The records do not support that the sample was 
taken in a laboratory setting. 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 lab services 
provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided August 9, 2021. 
 
You asked the Plan to pay for therapeutic activities. You say that please review all attached documentation 
supporting this request and process your claim for payment. The Plan denied your request. The Plan says the 
code is not appropriate for the service 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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 We find that CPT code 97530 is not supported in the medical record. Specifically, the records indicate that the 
service is performed by an occupational therapist assistant in a home health or hospice setting. There is an 
appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0158) for the billed service. It is 
noted that multiple attempts were made to contact the provider for additional information without success. 
Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been 
met. Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided 
August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic cardiovascular risk assessment testing provided 
August 17, 2021. 
 You asked the Plan to pay for genetic cardiovascular risk assessment testing. You say that please see attached 
medical records supporting billed charges. The Plan denied your request. The Plan says the services are not 
covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic cardiovascular risk assessment testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Medicare only covers a 
lipid panel consisting of a total cholesterol, HDL cholesterol, and triglyceride once every 5 years as 
cardiovascular screening Therefore, we decided that the Plan does not have to pay for genetic cardiovascular 
risk assessment testing provided August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
November 18, 2021. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that there is $0 copayment 
for telehealth visits. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. The Plan also says that telehealth visits with no cost sharing stopped on May 31, 2021. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for a specialist telehealth visit.  
 
The Plan confirmed that the cost sharing waiver for telehealth visits stopped on May 31, 2021. You have been 
asked to pay a $20 copayment for a specialist telehealth visit. A specialist telehealth visit falls 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 copayment for a specialist telehealth visit provided on November 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient rehabilitation therapy services rendered by the 
out-of-network (OON) provider from October 1, 2021, through October 28, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the outpatient rehabilitation therapy services rendered by the out-of-network 
(OON) provider from October 1, 2021, through October 28, 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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
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 there is limited documentation provided. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical and 
lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says services that are not medically necessary are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no medical 
records detailing a recent history, and there is no physical exam present in the submitted materials. Absent this 
information, the medical necessity of the requested MRI cannot be assessed. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical and lumbar spine.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the injection, alpha 1 proteinase inhibitor (human), not otherwise 
specified, 10 mg (J0256) provided June 29, 2021. 
 
You asked the Plan to pay for the injection services. You say that please overturn the denial and pay the total 
expected amount for the enrollee. The Plan denied your request. The Plan says that experimental or 
investigational services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the injection services. Our reviewer says that 
the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found Alpha1-proteinase inhibitors (Aralast NP, Glassia, Prolastin-C, and Zemaira ) are proven for 
chronic augmentation and maintenance therapy of patients with emphysema due to congenital deficiency of 
alpha1-proteinase inhibitor (A1-PI), also known as alpha1-antitrypsin (AAT) deficiency. The review has 
determined that the documentation supports that the alpha 1 proteinase inhibitor (human) is medically 
reasonable and necessary for the patient. The documentation supports that the alpha 1 proteinase inhibitor 
(human) is safe and effective for the patient. 
 
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 injection services have been met. Therefore, we decided that the Plan has to 
pay for the injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg (J0256) provided 
June 29, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that the enrollee lives in a rural area and 
requires medical care from various specialists that are not available close to his home. The Plan denied your 
request. The Plan says you are requesting an additional 131 miles for a total of 181 miles and your benefit only 
allows 50 miles. The Plan also says you have exceeded your benefit limit. 
 
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 up to 100 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional transportation 
mileage (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prolonged office visit (99417) on November 17, 2021. 
 
You asked the Plan to pay for a prolonged office visit. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99417 has a status indicator of I on the Physician Fee Schedule. This means that it is invalid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of a 
prolonged office visit have not been met. Therefore, we decided that the Plan does not have to pay for a 
prolonged office visit (99417) on November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to a Long-Term Acute Care Hospital (LTACH). 
 
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 was admitted with a leg fracture and required operative intervention for 
orthopedic hardware infection. The record indicates that the enrollee is improving but still requires acute care 
services. The enrollee continues to receive acute care services and these have not been denied. The medical 
record does not indicate that the enrollee requires services that she is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long-term acute care hospital (LTACH).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428-
HN, A0425-HN) provided on November 9, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that the enrollee was not admitted to the skilled 
nursing facility at the time of services. The Plan denied your request. The Plan says the enrollee was admitted 
to the skilled nursing facility from November 5, 2021, to November 16, 2021. Therefore, the payment for this 
ambulance transport is included in the SNF prospective payment system. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find 
that separate payment for these services is not supported in the record. Specifically, the record shows that the 
enrollee was inpatient status at the skilled nursing facility on the date in question. This means that the transport 
cost is included in the payment to the facility. Based on this information, we decided that Medicare rules for 
coverage of the ambulance transport have not been met. Therefore, we decided that the Plan does not have to 
pay for the non-emergent ambulance transportation services (A0428-HN, A0425-HN) provided on November 
9, 2021.