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

 
We decided that the Plan does not have to pay for the skilled nursing facility services provided from October 4, 
2021, through October 29, 2021. 
 
You asked the Plan to pay for the skilled nursing facility services. You say that you would like this approved 
for payment. The Plan denied your request. The Plan says a provider must be enrolled in the Medicare program 
for payment to be made. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility services 
provided from October 4, 2021, through October 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291, 99292) provided to the enrollee 
on July 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation did not include the time spent providing this service. 
 
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 the denied codes is: 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 
 
CPT 99292: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, there was no 
documentation showing the time spent providing the critical care services. This documentation is necessary as 
these are time-based codes. 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 critical care services 
(99291, 99292) provided to the enrollee on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 22, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says payment cannot be made for the 
ordered testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
on October 22, 2021, have been met. In this case, no medical records were provided from the enrollees ordering provider. Without these medical records, we are unable to determine if the ordered testing was 
medically reasonable and necessary based on the enrollees clinical history. Therefore, we decided that the Plan 
does not have to pay for the genetic testing services provided on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 11, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not billed with the appropriate modifier. 
 
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 codes 88104, 88305, 88312, and 88361 are not supported in the medical record. Specifically, 
these codes have a PC/TC indicator of 1, meaning they need a 26 or TC modifier. This is not apparent on the 
claim. 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 laboratory services provided to the enrollee 
on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 28, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 codes 88341, 88342, 88360, 88381 are not supported in the medical record. Specifically, 
these codes a PC/TC indicator of 1, meaning that they require a TC or 26 modifier. This was not done in this 
case. 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 laboratory services provided to the enrollee on 
March 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for the follow-up office visits 
to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the services. You say that you would like the out-of-network services to be 
processed as in-network. The Plan denied your request. The Plan says they have in-network providers that 
provide the services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
You can receive out-of-network services, but your out-of-network cost-share would apply. The Plan provided a 
list of in-network providers that can give you the services that you need. Therefore, the Plan does not have to 
pre-approve an in-network exception for the follow-up office visits to be provided by an out-of-network 
provider. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for the 
follow-up office visits to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are reasonable and necessary for the 
enrollee's current illness. The Plan denied your request. The Plan says that daily skilled nursing needs are not 
required, and it appears the enrollee's needs can be met at a lower 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 pre-approve SNF care. Our reviewer says that the 
requested admission not medically reasonable and necessary. Our physician reviewer found the enrollee does 
qualify for SNF coverage. The enrollee does have documented skilled nursing needs. The enrollee has a new 
ostomy, for which monitoring, care and teaching are required. The enrollee does have documented skilled 
therapy needs. The enrollee appears to be functioning below her baseline following open abdominal surgery. A 
period of daily skilled services is reasonably required to establish a maintenance program and/or to prevent 
deterioration of the enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aortography services (75630-26-XU) provided on September 
17, 2021. 
 
You asked the Plan to pay for aortography services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this service is inclusive to another billed 
code and no separate payment will be made. 
 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 75630 is a column II code to column I code 37221; however, 75630 
was billed with a modifier.  
 
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 aortography services. Our reviewer says that the 
documentation does not support payment for the services billed. Our reviewer found the procedure report 
describes diagnostic angiography followed by therapeutic intervention. Per operative report "After diagnostic 
angiography was performed, a 7 French sheath was placed in the contralateral left external iliac artery and a 6 x 
60 mm self-expanding stent was placed. A second 6 x 60 mm stent was placed in the right external iliac artery 
following withdrawal of the sheath into the right common femoral artery. Final angiogram demonstrated 
significant morphologic improvement with brisk in-line flow and no significant residual stenosis. Meanwhile, 
the National Correct Coding Initiative (NCCI) 2021 Coding Policy states Open and percutaneous 
interventional vascular procedures include operative angiograms and/or venograms, which shall not be 
separately reported as diagnostic angiograms/venogram. This review supports that no separate payment can be 
made for this service per Medicare rules. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aortography services have not been met. Therefore, we decided that the Plan 
does not have to pay for aortography services (75630-26-XU) provided on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 10, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says laboratory testing related to treatment of end-stage renal disease is bundled into dialysis services 
and is not separately reimbursable. 
 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trifocal lenses provided on January 12, 2022. 
 
You asked the Plan to pay for trifocal lenses. You say that you need trifocal glasses, and the lab no longer 
makes trifocals. You say that you paid $350 but only $128 is your responsibility. The Plan denied your request. 
The Plan says standard lenses and frames are only covered every 2 years.  Medicare generally does not cover routine vision and eyewear services. 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 standard frames and lenses every 2 years. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of trifocal lenses have not been met. Specifically, the Plan paid for frames and lenses purchased on 
September 21, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay 
for trifocal lenses provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint. You say that this treatment is 
medically necessary based on the enrollee's clinical scenario. The Plan denied your request. The Plan says the 
use of radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide a clear 
long-term benefit over standard treatment. 
 
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 radiofrequency ablation of the 
sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found this is considered experimental/investigational 
because of the wide variation in efficacy reported in the 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 radiofrequency ablation of the sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulatory surgical center visit 
provided on February 3, 2022. 
 
You asked the Plan to waive the copayment for ambulatory surgery. You say that you were told the services 
would be covered in full, but you received a bill for $175. You say that if you had known you would be 
charged, you would not have proceeded with surgery. The Plan denied your request. The Plan says the 
copayment was applied correctly in accordance with your contract with the Plan. 
 
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 $175 
copayment for each Medicare-covered ambulatory surgical center visit.  
 
You have been asked to pay a $175 copayment for ambulatory surgery. Ambulatory surgery falls within the 
outpatient surgery benefit category. Outpatient surgery includes services provided at hospital outpatient 
facilities and ambulatory surgical centers. Since you received services in an ambulatory surgical center, 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 ambulatory surgical center visit provided on  
February 3, 2022.
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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 patient was admitted for hypotension and fall after recent total knee replacement and was transferred to skilled nursing on June 30, 2022. There is ongoing weakness. 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 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. In conclusion, 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. 
 
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: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve intra-dialytic parenteral nutrition (IDPN.) 
 
You asked the Plan to pre-approve IDPN. You say that the medical records provided support the need for 
IDPN. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that parenteral nutrition is covered when 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 IDPN. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found IDPN is indicated as the enrollee has been 
counseled on high protein intake and has continued to lose weight.  The enrollee's body mass index (BMI) is 
falling and IDPN is indicated due to inadequate nutrition and negative outcomes associated with malnutrition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IDPN have been met. Therefore, we decided that the Plan has to pre-approve 
intra-dialytic parenteral nutrition (IDPN.)  
 
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: 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 the requested IRF care is medically reasonable and 
necessary. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 patient was admitted for respiratory failure, congestive heart failure, and 
chronic obstructive pulmonary disease. 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 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. In conclusion, 
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. 
 
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.