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

 
We decided that the Plan does not have to pre-approve the Minuteman G3-R fusion plate for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered investigational and experimental. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this plate is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Minuteman G3-R fusion plate for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care services (99232) provided on February 11, 
2022. 
 
You asked the Plan to pay for hospital care services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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hospice election has been revoked or terminated.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 February 5, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital care 
services (99232) provided on February 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided (71045) on January 30, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the services should be covered as you disagree with the 
charges. The Plan denied your request. The Plan says the services denied correctly as they were non-emergent 
and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an x-ray provided (71045) on January 30, 2022 by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for physical therapy. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on January 10, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as they were non-emergent 
and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an x-ray provided on January 10, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on February 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on February 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally-invasive sacroiliac joint fusion. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is investigational and therefore 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 pre-approve the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this request is still experimental for degenerative lower 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve minimally-invasive sacroiliac joint fusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management 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 the wrong amount of units were billed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64490 and 64491 is 1. The MAI value for this code is 2. You billed 2 units 
of this code, exceeding the MUE. 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 pain management 
services provided to the enrollee on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on September 11, 2021. 
 
You asked the Plan to pay for services provided at 24-hour facility, in addition to basic service (99053). You 
say that the coding department has reviewed the level of emergency evaluation and concluded that the coding 
done was best. The Plan denied your request. The Plan says procedure code 99283 has been overturned and 
procedure code 99053 remains denied as bundled services are not eligible for separate reimbursement.  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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic service 
(99053) provided on September 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of Skilled Nursing Facility (SNF) admission 
and services from December 19, 2021, to December 31, 2021. 
 
You asked the Plan to pay for continued SNF care. You say that these services were necessary and should be 
paid as they were covered by Medicaid. The Plan denied your request. The Plan says as of December 19, 2021, 
the enrollee only requires assistive or supportive care. The enrollee was not receiving therapy after December 
18, 2021, and has met their expected goals. Care is no longer medically necessary at the SNF level. 
 
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 continued SNF care. Our reviewer says that 
continued care at the SNF level was not medically necessary for the dates in question. Our physician reviewer 
found that there was no documentation that the enrollee required skilled nursing services which required the 
specialized skill, knowledge and judgement of a skilled professional nurse to safely and effectively provide 
medically necessary and reasonable treatment from December 19, 2021, to December 31, 2021. The records do 
not document the need for intravenous medications, new tube feeding, ostomy care or daily complex wound 
care. The enrollee did not require skilled therapy services during these dates and was documented as being able 
to walk household distances with a rolling walker with contact guard assistance and supervision for transfers. 
Based on the medical records provided, this enrollee did not require skilled nursing and skilled therapy services 
on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear to have 
been custodial from December 19, 2021, to December 31, 2021. 
 
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 pay for continuation of Skilled Nursing Facility (SNF) admission and services from December 
19, 2021, to December 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on 
February 18, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. The Plan denied your request. The Plan says 
the claim processed 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $100 copayment for outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers-outpatient hospital-surgery services.  
 
The enrollee has been asked to pay a $100 copayment for outpatient surgery. The outpatient surgery falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers-outpatient hospital-surgery services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided on 
February 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tezspire syringe. 
 
You asked the Plan to pre-approve Tezspire syringe. You say that this drug is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have 
not been met. 
 
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 Tezspire syringe. Our reviewer says 
that this drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer 
found that the Plan requires a trial of Dupixent before they will approve the requested drug. In this case, the 
record indicates that the enrollee has moderate uncontrolled asthma. The requested medication is a new start. 
The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the plan's preferred step one alternative. The elements of the coverage criteria 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 Tezspire syringe have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Tezspire syringe.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on September 9, 2021. 
 
  You asked the Plan to pay for services provided at 24-hour facility, in addition to basic service (99053). You 
say that the claim was denied stating level of service not supported. You say that the enrollee was in need of 
care as illustrated by the medical records. The Plan denied your request. The Plan says procedure code 99285 
has been overturned and procedure code 99053 remains denied as bundled services are not eligible for separate 
reimbursement. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic service 
(99053) provided on September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation (64625) provided on October 1, 
2021. 
 
You asked the Plan to pay for the radiofrequency ablation (64625). You say that the charges for the procedure 
and the extensive care provided are covered by Medicare. You say that you are requesting the denial be 
reversed and payment of the remaining balance be made. The Plan denied your request. The Plan says there is a 
more appropriate code to describe the services provided. 
 
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 64625 is radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography). 
  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the radiofrequency ablation (64625). Our reviewer says that 
the medical records do not support the use of procedure code 64625. Our reviewer found the procedure code 
description for 64625 is radiofrequency ablation of the sacroiliac joint. The procedure performed was 
destruction by neurolytic agent of genicular nerve branches including imaging guidance. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the radiofrequency ablation (64625) have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiofrequency ablation (64625) provided on October 1, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the surgical procedures on the nervous system (64625) provided to 
the enrollee on October 25, 2021. 
 
You asked the Plan to pre-approve these services. You say that this service is allowed by Medicare. The Plan 
denied your request. The Plan says that that radiofrequency ablation used for sacro-iliac joint pain is considered 
not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The procedure notes are 
for radiofrequency ablation of the lumbar facet joints, not the lateral sacral branches. Our physician reviewer 
found that the enrollee's condition meets 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 been met. Therefore, we decided that the Plan has to pre-
approve the surgical procedures on the nervous system (64625) provided to the enrollee on October 25, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays provided on October 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the x-rays. You say that you have an exclusive contract with the nursing home 
facility to perform the x-rays for the enrollee. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the x-rays. The Plan did not pre-approve the x-rays. We found no exception 
that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to 
pay for the x-rays provided on October 22, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
August 16, 2021, to October 13, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
indicates that the RAP was not submitted within 5 calendar days after the start of care date. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from August 
16, 2021, to October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on 
February 1, 2022. 
 You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the Medicare rule for payment of this 
claim 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. 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 computed tomography (CT) scan (70450) provided on 
February 1, 2022.