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

 
We decided that the Plan does not have to pay for an allograft (20930) provided on May 25, 2021. 
 
You asked the Plan to pay for an allograft. You say that this is supported in the records. The Plan denied your 
request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Physician Fee Schedule Database 
(MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment 
for other services not specified. 
 
We looked at the file and Medicare rules. Code 20930 has a status indicator of B and is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of an allograft have not been met. 
Therefore, we decided that the Plan does not have to pay for an allograft (20930) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection with an ultrasound provided on September 9, 
2021, by an OON provider. 
 
You asked the Plan to pay for the injection with an ultrasound. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 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 the injection with an ultrasound provided on 
September 9, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213, 3079F, 3075F) provided on October 9, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan and the services were 
not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 (99213, 3079F, 3075F) provided on 
October 9, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from April 3, 2020, to April 4, 
2020. 
 
You asked the Plan to pay for the inpatient care. You say that the claim was first billed on April 16, 2020. The 
Plan denied your request. The Plan says the claim was not filed within 12 months or 1 calendar year from the 
date of service in this case. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient care was not filed until October 29, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the inpatient care provided from April 3, 2020, to April 4, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not 
require daily skilled nursing or therapy 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 SNF services. Our physician reviewer 
found that you were admitted to the hospital after a fall at home with resulting rib fractures. The most recent 
therapy documentation indicates you are able to ambulate short distances with stand by assistance using a 
rolling walker. You are medically stable without any acute exacerbations of chronic medical problems. Your 
physical function is at or near your baseline. An admission to a SNF for inpatient skilled services is 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services (97110) provided 
on September 30, 2021, and October 5, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 $25 
copayment for Outpatient rehabilitation services.  
 
You have been asked to pay a $50 copayment for two physical therapy visits ($25 x 2 = $50). Physical therapy 
services 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 copayment for physical therapy services (97110) provided on September 30, 2021, and October 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not have daily skilled needs that can be provided only on an inpatient basis. 
 
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 services. Our physician reviewer 
found that the enrollee was admitted to the hospital due to difficulty breathing. She was diagnosed with a 
urinary tract infection with sepsis and hyponatremia. The most recent therapy documentation indicates the 
enrollee is at her baseline functional status. She is medically stable without any acute exacerbations of chronic 
medical problems. An admission to a SNF for inpatient skilled rehab services is 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy provided from September 8, 2021, 
through October 29, 2021. 
 
You asked the Plan to pay for medical nutrition therapy. You say that you should not have to pay anything. The 
Plan denied your request. The Plan says chiropractic services are only covered for spinal manipulations. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for medical nutrition therapy provided from September 8, 2021, through  
October 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you had low hemoglobin and have not been able to 
participate in therapy to increase your strength and endurance. The Plan denied your request. The Plan says the 
stay is not medically necessary based on SNF criteria. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready 
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although 
further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent 
skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can 
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your records do not show require daily nursing or daily therapy services 
on an inpatient basis. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the chest x-ray (71045) provided on November 4, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service 
was rendered in the correct place of service. The Plan denied your request. The Plan says that this claim was 
not billed with the correct place of service code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence to support that the enrollee 
was registered inpatient on the billed date of service. Therefore, we decided that the Plan has to pay for the 
chest x-ray (71045) provided on November 4, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services from April 15, 2022, through 
April 19, 2022. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that inpatient hospital care was not necessary. 
 
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 pre-approve inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. You presented with weakness and recent fall from toilet and were found to have a urinary tract infection after workup in emergency 
department. You were treated with antibiotics and fluids. You tolerated oral and were able to walk using 
walker. Other acute conditions were ruled out, and you were stable. There is insufficient support made for 
inpatient services. The records do not suggest you required hospital services that would likely cross 2 
midnights. Our physician reviewer found that your condition does not meet criteria for coverage of inpatient 
hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services from April 15, 2022, through April 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional speech therapy visits. 
  You asked the Plan to pre-approve additional speech therapy visits. You say that speech therapy will allow the 
enrollee to increase her independence and participation in her medical care, which could prevent future 
hospitalizations. You also say that the enrollee has made significant progress and is likely to meet all goals if 
given more visits. The Plan denied your request. The Plan says additional speech therapy visits are not 
medically necessary. 
 
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 additional speech therapy 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 the patient has had prior therapy and has a home 
program she is participating in. Her deficits do not require ongoing skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional speech therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional speech therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 the laboratory services rendered on August 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a dermatologist referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the notes do not show that your regular doctor cannot care for your condition. 
 
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 the referral. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found a referral for dermatology is needed to distinguish skin cancer from the precancerous lesions that you 
have. 
 
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 referral have been met. Therefore, we decided that the Plan has to pre-
approve a dermatologist referral.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 13, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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 the denied codes is: 
 
CPT 29826: 
 
Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with 
coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary 
procedure) 
 
CPT 23440:  
Resection or transplantation of long tendon of biceps 
 
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 the operative report describes all 
procedures performed on the right shoulder.  Medicare considers the shoulder to be a single structure; thus, 
CPT 29826 is considered to be a component of CPT 23412 and would not be reported separately. In terms of 
CPT 23440, the operative report does not include documentation of resection or transplantation of long tendon 
of biceps. The operative report documents "Biceps tendon: Significant biceps synovitis noted over the biceps 
attachment. The biceps tenotomy is completed." In this case, this procedure cannot be verified.  
 
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 surgical services provided to the enrollee on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve procedure called percutaneous neuromodulation 
therapy (or PNT) (64555) and an implantable neurostimulator (L8679). 
 
You asked the Plan to pre-approve a nerve procedure and an implantable neurostimulator. You say that the 
requested nerve procedure is medically necessary. The Plan denied your request. The Plan says the requested 
nerve procedure does not meet criteria. 
 
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 nerve procedure and an implantable 
neurostimulator. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is insufficient data to support that percutaneous 
neuromodulation therapy is medically reasonable and necessary to treat the enrollee's conditions of chronic 
pain syndrome, unspecified neuralgia and neuritis, low back pain, cervicalgia, and pain in the bilateral feet and 
arms. It has not been shown that percutaneous neuromodulation therapy is at least as beneficial as existing and 
available medically appropriate alternatives for the enrollee's conditions. 
 
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 nerve procedure and an implantable neurostimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a nerve procedure called percutaneous 
neuromodulation therapy (or PNT) (64555) and an implantable neurostimulator (L8679).