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

 
We decided that the Plan does not have to pre-approve an inpatient admission for decompressive laminectomy 
and fusion using local autograft, banked bone allograft and, possible bone morphogenic protein, L4-5. 
 
You asked the Plan to pre-approve an inpatient admission for decompressive laminectomy and fusion using 
local autograft, banked bone allograft and, possible bone morphogenic protein, L4-5. You say that an inpatient 
admission for decompressive laminectomy and fusion using local autograft, banked bone allograft and, possible 
bone morphogenic protein, L4-5 is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet the InterQual coverage criteria for both the surgery and the inpatient admission. 
 
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 an inpatient admission for 
decompressive laminectomy and fusion using local autograft, banked bone allograft and, possible bone 
morphogenic protein, L4-5. Our reviewer says that an inpatient admission for decompressive laminectomy and 
fusion using local autograft, banked bone allograft and, possible bone morphogenic protein, L4-5 is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that there is no need for spinal fusion or an inpatient admission. The enrollee has lumbar degenerative disc and spinal stenosis. A 
simple lumbar decompression surgery may be safely performed as an outpatient level of care. Fusion and 
inpatient stay are not needed. There is no spinal instability. 
 
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 inpatient admission for decompressive laminectomy and fusion using local 
autograft, banked bone allograft and, possible bone morphogenic protein, L4-5 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an inpatient admission for decompressive laminectomy 
and fusion using local autograft, banked bone allograft and, possible bone morphogenic protein, L4-5.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (30465, 30117, 31288, 31267, 30140) provided 
on January 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that claims submitted 
where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 
 
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 services. Our reviewer says that codes 30465 and 30117 
are not supported. Our reviewer found the provided medical records do not support the use of procedure codes 
30465 and 30117. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 30465 and 30117 have not been met. 
 
In this case, the MUE for CPT codes 31288, 31267, and 30140, is 1. The MAI value for this code is 2. You 
billed 2 units of each of these codes, 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 the services (30465, 30117, 31288, 31267, 30140) provided on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $10 copayment for a for a lab service on February 2, 2022. 
 
You asked the Plan to waive the $10 copayment for a lab service. You say that you should not have a $10 
copay because this was a routine lab service. The Plan denied your request. The Plan says There is a $10 copay 
for lab services with this 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 $10 
copay for lab services.  
 
You have been asked to pay $10 copay for a lab service. Lab services fall within the Medical Benefits Chart 
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 $10 copayment for a for a lab service on 
February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
provided in good faith. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 lab services provided on February 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (14301, 38792) provided on November 16, 
2021.  
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
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 14301 is "Adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm". 
 
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 services. Our reviewer says that the use of code 14301 is 
not supported by the records provided. Our reviewer found that the documentation submitted describes a 
subcutaneous flap, which would not be reported with adjacent tissue transfer (pedicle). The operative report 
documents: "The surrounding breast parenchymas was then mobilized and closed in layers with 3-0 vicryl to 
obliterate the segmental mastectomy defect, which accounted for 45 cm2 of local tissue arrangements".  
Simple, intermediate and complex layered closures are inclusive to CPT code 19301. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 14301 have not been met. 
 
In this case, we have confirmed that code 38792 is a column II code to column I code 38900. 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 (14301, 38792) provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the rendering provider is an in-network provider 
with the Plan, and you do not need an authorization. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The 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 provided on December 30, 2021, by 
an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) provided 
to the enrollee on September 24, 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 for CPT 99284 to be applicable, the severity of presenting problem must be high, and there must 
be a detailed history and exam. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function." 
 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case there was no 
documentation of medical decision making of moderate complexity, not the high complexity required by CPT 
99284 The review has determined that  the services rendered were more accurately represented by CPT 99283. 
The presenting problems were moderate, not high severity. There was an expanded problem-focused exam and 
history, not a detailed exam and history. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99284) provided to the enrollee on September 24, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for X-rays of the wrist and hand provided on 
February 11, 2022. 
 
You asked the Plan to waive the copayments for the X-rays. You say that you are on a limited income and 
cannot afford the copayments. 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 $15 
copayment for each standard X-ray service.  
 
The file shows you had a total of 4 separate X-ray images. You have been asked to pay a $15 copayment for 
each of the X-rays, for a total of $60 ($15 copayment x 4 images = $60). The X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 X-rays of the wrist and hand provided on February 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ambulance services provided on February 
3, 2022. 
 
You asked the Plan to waive the coinsurance for the ambulance services. You say that you developed a blood 
clot and needed to be transported for an ultrasound. The Plan denied your request. The Plan says the 
coinsurance was 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 18% 
coinsurance regardless of the number of trips for both ground and air ambulance. 
 
You have been asked to pay $76.77 (allowed amount = $426.51 x 18%) for the ambulance services. The 
ambulance services fall within the Ambulance 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 coinsurance for ambulance services provided on February 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exploration of penetrating wound (20103) and 
debridement (11012) provided on December 27, 2021. 
  You asked the Plan to pay for the exploration of penetrating wound (20103) and debridement (11012). You say 
that authorization was not required for these procedures and the claim should be reprocessed for payment. The 
Plan denied your request. The Plan says procedure codes 26075, 26420, and 26437 were approved. The Plan 
also says procedure codes 20103 and 11012 were not billed with a modifier to indicate separate and distinct 
services. 
 
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 20103 
and 11012 are column II codes to column I code 26075. These codes have 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 exploration of penetrating wound (20103) and 
debridement (11012) provided on December 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says there have been twenty visits so far. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that based on the available records, you appear to have improved with 
therapy to the point of having less pain and are "doing well with mobility and maintaining exercises." After the 
now 24 approved physical therapy treatments, records do not support that the complexity of your conditions are 
such that the skills of a professional therapist are required to achieve further improvement in your symptoms or 
functional status. Further utilization of the home exercise program appears appropriate at this point.   
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided to the enrollee on 
December 1, 2021. 
 
You asked the Plan to pay for the ECG. You say that this should be paid for. The Plan denied your request. The 
Plan says this service should not be unbundled. 
 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 93010 
is a column II code to column I code 33017. 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 an electrocardiogram (ECG) provided to the enrollee on 
December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. 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 June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left leg percutaneous arterial angioplasty and 
revascularization for femoral, popliteal, tibial and peroneal arteries 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 the arterial duplex study does not show more than 50% stenosis of 
the left iliac artery. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient has a 
known occlusion of the left superficial femoral artery (SFA). He is status post left SFA stenting. While there is 
mention of burning and fatigue there is no documentation that the patient is having lifestyle limiting symptoms 
as result of this. There is no documentation of rest pain or tissue loss. There is no documentation of any limb 
threat. It is documented that he has no trouble walking. He is only recently stopped smoking. Medical necessity 
of an intervention without documentation of lifestyle limiting claudication or limb threat. 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 left leg percutaneous arterial angioplasty and revascularization for femoral, popliteal, tibial 
and peroneal arteries for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for acupuncture services provided on 
February 21, 2022. 
 
You asked the Plan to waive the coinsurance for the acupuncture services. You say that you should not have a 
copayment for acupuncture. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 50% 
coinsurance for acupuncture services.  
 
The file shows that the Plan reprocessed the claim to remove the additional $35 copayment for a specialist visit. 
Therefore, you have been asked to pay $21.61, which is 50% of the allowed amount for the acupuncture 
services ($43.22 allowed amount x 50% coinsurance = $21.61). The acupuncture services fall within the 
Acupuncture for Chronic Low Back Pain 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 acupuncture services provided on February 21, 2022.