Persius/hicric huggingface dataset:
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 the 
services are not medically necessary. Our physician reviewer found the hospital discharge summary indicates 
that you were discharged to a skilled nursing facility, but the documentation provide by the health plan policy 
indicates that you are currently at home. Because there is no clinical documentation provided after your 
discharge from the hospital on August 12, 2022, it cannot be determined if you continue to require skilled 
nursing facility care given your current needs for medical oversight and therapy services. Therefore, the 
requested skilled nursing facility care cannot be considered medically necessary. 
 
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 70544 billed for date of service March 9, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one hundred sixty (160) visits for hemodialysis to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you have been going to this 
provider for over seven years; since you first got diagnosed and needed to get dialysis. You state that this 
facility, although is not currently contracted, is a lot closer and easier to get to then the contracted locations. 
You state this provider is familiar with you and your care. The Plan denied your request. The Plan says they 
have other dialysis centers which are contracted with the Health Plan in your proximity that can help you. 
 
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 
one hundred sixty (160) visits for hemodialysis to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 13, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 71111. 
 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 71045 
is a column II code to column I code 71111. 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 71045 billed for date of service March 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on December 23, 2021, to February 
8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that the three visits were urgent, and you would like the 
claims paid. The Plan denied your request. The Plan says no prior authorization was obtained, and you can 
travel back to the service area to be seen by network providers. 
 
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 office visits. The Plan did not pre-approve the office visits. We found no exception that would require the Plan to pay for the office visits. Therefore, we decided that the Plan does 
not have to pay for the office visits provided on December 23, 2021, to February 8, 2022, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network (OON) osteogenesis stimulator 
(E0748). 
 
You asked the Plan to pre-approve an OON osteogenesis stimulator. You say that the enrollee is in the high-
risk category for unsuccessful fusion and in-network providers cannot meet the enrollee's special medical 
needs. The Plan denied your request. The Plan says there is no data that demonstrates any improved outcomes 
with one brand of bone growth stimulator compared to another. The Plan also says the in-network option is 
appropriate. 
 
The Plan follows Medicare rules. Medicare rules say that the physician or treating practitioner must document 
in the beneficiarys medical record the reason why the specific brand or mode of delivery is necessary to avoid 
an adverse medical outcome. 
 
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 an OON osteogenesis stimulator. Our 
reviewer says that this request is not medically necessary. Our physician reviewer found there is no specific 
clinical rationale for the requested out-of-network bone stimulator. Our reviewer also found that there is no 
medical necessity for the specific brand being requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an OON osteogenesis stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an out-of-network (OON) osteogenesis stimulator (E0748).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided on January 14, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test was validated in a clinical study. The 
Plan denied your request. The Plan says the testing was not necessary for the diagnosis listed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing services. Our physician reviewer 
found that the CxBladder is not considered a screening test for urothelial cancer. Cystoscopy, ureteroscopy, 
possible biopsy and upper tract imaging will still be necessary regardless of the results of CxBladder testing. 
Urinary biomarker tests such as CxBladder give significant false-negative results in patients with urothelial 
cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. 
Therefore, the CxBladder testing provided was not medically necessary for the treatment of the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder test provided on January 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for therapy sessions provided from February 
23, 2022, to March 30, 2022. 
 
You asked the Plan to waive the copayments for therapy sessions. You say that you go to all three kinds of 
therapy each day and must pay $30 for each one and you need to get the billing cleared up. The Plan denied 
your request. The Plan says the copayments applied are correct. 
 
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 $30 
copayment per day for Medicare covered physical therapy, occupational and speech services.  
 
You have been asked to pay $690 ($30 x 23 sessions) copayment for therapy sessions. Therapy sessions fall 
within the Outpatient Rehabilitation Services 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 copayments 
for therapy sessions provided from February 23, 2022, to March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sacroiliac (SI) joint radiofrequency ablation provided to the 
enrollee on January 11, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the services do not meet the coverage criteria requirements. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the 
diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and 
investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of SI joint pain.  Radiofrequency ablation for denervation, whether performed using traditional, 
cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for sacroiliac (SI) joint radiofrequency ablation provided to the enrollee on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on November 25, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
this service should be covered since a family member called for the ambulance because you passed out. The 
Plan denied your request. The Plan says this service is not covered under your contract under any normal 
circumstances since no transportation was provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 25, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The records show that you declared you did not want to be transported to the emergency room and refused 
transportation. Therefore, we decided that the Plan does not have to pay for the ambulance response and 
treatment with no transport (A0998) provided on November 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission for a right reverse total shoulder 
arthroplasty provided to the enrollee on April 7, 2022, and April 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says there is no documentation provided to support that the expectation that 
the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that in this case, the record indicates that the enrollee underwent total shoulder 
arthroplasty and was discharged the day following surgery. The record provided does not support a reasonable 
expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors that 
must be documented in the medical record. The initial day should have been spent in observation until it is 
clearly expected that a second midnight would be required, at which time the physician may order inpatient 
admission. The record does not indicate that inpatient admission was necessary. 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient admission for a right reverse total shoulder arthroplasty provided to 
the enrollee on April 7, 2022, and April 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you are appealing the denial of SNF 
admission. The Plan denied your request. The Plan says criteria for admission to the SNF has not been met. 
Skilled services can be provided on an intermittent outpatient basis, in a long-term care facility, or at the home 
with home health care services. 
 
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 the SNF admission. Our reviewer says 
that clinical documentation shows that you require intravenous antibiotics, wound care and recovering from 
multiple other complications thus would require the assessment and treatment by a professional nurse. 
Evaluating therapists state that you have functional impairments and would benefit from home health thus you 
would also require skilled therapy. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. Our reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SNF admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. 
She has not tried and failed the Plan's required drugs, Ferrlecit, Infed, or Venofer. The records do not show that 
the required drugs would be contraindicated or less effective; therefore, the Feraheme is not reasonable or 
medically necessary. 
 
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 Feraheme.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional surgical services provided to the enrollee on 
March 24, 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 three separate services are not supported as performed in the records. 
 
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 22511: 
Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral 
injection, inclusive of all imaging guidance; lumbosacral 
 
CPT 22512: 
Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral 
injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body 
(List separately in addition to code for primary procedure) 
 
CPT 99152: 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
There is no evidence that these denied services were rendered three times. Two copies of same operative report 
were submitted by the provider. 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 additional surgical 
services provided to the enrollee on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the rendering physician is a hospitalist and depends 
on the hospital staff to obtain proper authorization. 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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on January 11, 2022, by an out-of-network (OON) provider.