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

 
We decided that the Plan does not have to waive the coinsurance for the intracardiac electrophysiological 
studies you received on May 12, 2021. 
 
You asked the Plan to waive the coinsurance for the intracardiac electrophysiological studies. You say that the 
cost of these services should be included in the cost of the surgery. The Plan denied your request. The Plan says 
you were charged this coinsurance correctly. 
 
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 20% 
coinsurance for diagnostic procedures and tests.  
 Your Evidence of Coverage says that when you have an outpatient surgery, separate cost sharing applies for 
any diagnostic procedures and tests you may receive. You have been asked to pay 20% coinsurance for the 
intracardiac electrophysiological studies. The intracardiac electrophysiological studies fall within the diagnostic 
procedures and tests 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 coinsurance for the intracardiac 
electrophysiological studies you received on May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had a late effect stroke and seizure activities 
which caused you to be admitted. The Plan denied your request. The Plan says you can safely receive the 
services you need in other setting, 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 you are currently stable medically, do not meet Centers for Medicare & Medicaid 
Services (CMS) coverage criteria for an IRF admission for the following reasons: At the current medical 
stability and lack of medical complexity, there is no need for physical medicine and rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. No documented skilled nursing needs. Based upon your 
current level of function and dependence, you do not require an intensive, complex, multidisciplinary approach 
to daily therapy. You need physical therapy (PT) and occupational therapy (OT) in an alternate low intensity 
level. You do not need a therapy program consisting of at least 3 hours of therapy per day at least five (5) days 
per week with an interdisciplinary approach to rehabilitation care. You will not make a significant functional 
progress in a reasonable period of time as predicted. IRF admission is not medically necessary. While you may 
benefit from physical therapy (PT) and occupational therapy (OT), your rehabilitation needs can be safely met 
in an alternate and low intensity setting such as a skilled nursing facility (SNF). 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (R0070) provided on May 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly.  
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. In this case place of service (POS) code 31 would indicate that the 
enrollee was in a Part A covered stay. This means that the setup and transport would not be billable to the plan 
by the provider, but by the SNF. Therefore, reporting POS code 31 is not appropriate. The correct POS code 
would be 32, which indicates a non-covered SNF stay. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the services (R0070) provided on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 1, 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 records do not support the services 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the place of 
service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The 
claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of 
a doctor's office (POS 11). 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 April 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on July 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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, 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 the services (70450) provided on July 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable


We decided that the Plan does not have to waive the copayment for surgical injection services (20610) 
provided on June 1, 2021. 
 
You asked the Plan to waive the copayment for injection services. You say that the services should be covered 
The Plan denied your request. The Plan says the copayment applied correctly. 
 
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 $45 
copayment for Physician/Practitioner services, including doctor?s office visits.  
 
You have been asked to pay a $32.60 copayment which is less than the $45 copayment for injection services. 
Injection services fall within the Physician/Practitioner services, including doctor?s 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 surgical injection services (20610) provided on 
June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of atezolizumab. 
 
You asked the Plan to pre-approve atezolizumab. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for atezolizumab is correct, because this 
drug is only approved in this setting with PD-L1 greater than or equal to 1 non-small cell lung cancer who 
received previous adjuvant chemotherapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 atezolizumab. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested use of atezolizumab. Our physician reviewer 
found atezolizumab is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The 
requested use is not supported by one of the major drug compendia or by clinical research appearing in a 
Medicare-approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of atezolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of atezolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99214) rendered on 
April 8, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you went to the provider, 
who was supposed to do a scope of your throat, and the provider did not do it. You also say that since the 
provider did not do what he was supposed to do with the scope, you do not believe you should pay this. 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 $35 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctor's 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 office visit (99214) rendered on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cytopathology procedures (88121) provided June 14, 
2021.  

You asked the Plan to pay for the screening testing services. You say that resending this as this is an allowable 
procedure with 88112-26, along with the office visit note and the fish/cytology for medical necessity. The Plan 
denied your request. The Plan says CPT code 88121 is not a Medicare benefit for the diagnosis listed on the 
claim and is done for screening purposes. 
 
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 screening testing services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Cytopathology Procedures (88121) are not medically necessary. The medical records 
do not substantiate this service. 
 
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 screening testing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the Cytopathology procedures (88121) provided June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of lesion of spermatic cord represented by code 
55520-59-LT provided on April 27, 2021. 
 
You asked the Plan to pay for code 55520-59-LT. You say that the medical records support the billing of code 
55520-59-LT The Plan denied your request. The Plan says the medical records do not support the billing of 
code 55520-59-LT 
 
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 code 55520-59-LT Our reviewer says that 
the medical records do not support the billing of code 55520-59-LT. Our physician reviewer found the modifier 59 would not be appropriate unless the excision of the lesion was performed through a separate incision or 
during a separate operative session from the hernia repair. The bundling edit on these two procedures is based 
on the CPT 'separate procedure' designation on CPT code for the excision of spermatic code lipoma. Per CPT 
instructions, a code with this designation is one that is "commonly carried out as an integral component of a 
total service or procedure" and should only be reported separately with a modifier when "it is a distinct, 
independent procedure. This may represent a different session, different procedure or surgery, different site or 
organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive 
injuries)." 
 
Cord lesions are very commonly removed during many inguinal hernia repair surgeries, and billing routinely as 
a separate procedure would be considered inappropriate unbundling unless the documentation supports it is 
distinct from the main procedure and medically necessary as a separate surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 55520-59-LT have not been met. Therefore, we decided that the Plan does 
not have to pay for the excision of lesion of spermatic cord represented by code 55520-59-LT provided on 
April 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a 100 day limit for these services. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period. The 100th day of skilled 
nursing facility services in this case will be November 20, 2021. The Plan has covered 100 days of SNF care. 
 
 
 
 
 
 
 
 
  
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Percutaneous Vertebral Augmentation (PVA) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records do not show the enrollee meets criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that PVA can be covered if LCD criteria are met. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient is not in 
an osteoporosis management program. Also, recent literature shows the procedure is not better than sham 
treatment. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 
these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Percutaneous Vertebral Augmentation (PVA) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex Superion device. 
 
You asked the Plan to pre-approve a Vertiflex Superion device. 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. 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 a Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is experimental. 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 a Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from 
November 12, 2021, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that this enrollee cannot be discharged 
to their home but is in need of skilled nursing care full time, and ongoing physical therapy (PT), the enrollee's 
home environment is unsafe for them to live home alone and navigate alone. The Plan denied your request. The 
Plan says the stay is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found this enrollee does not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of November 12, 2021, forward and could have been treated in a 
lesser restrictive setting as they were not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant 
while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from November 12, 2021, 
forward.
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies with pump (A4222) provided from 
April 28, 2021, to April 30, 2021. 
 
You asked the Plan to pay for the infusion supplies from April 28, 2021, to April 30, 2021. You say that the 
enrollee revoked their hospice benefit prior to the dates of service in this case. The Plan denied your request. 
The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage 
of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 15, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the infusion supplies 
with pump (A4222) provided from April 28, 2021, to April 30, 2021.