Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital care admission. 
 
You asked the Plan to pre-approve inpatient admission. You say that the services should be covered. You say 
that you were in a great deal of pain. You also say that you do not understand how your plan does not cover 
this medical emergency. The Plan denied your request. The Plan says the inpatient admission is not medically 
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 admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the provided documentation indicates that your vital signs remained normal, and your 
hemoglobin remained stable. The reviewer found that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that your necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an acute inpatient hospital care admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on January 1, 
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 this should not be reported separately. 
 
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 99140 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99140 is not separately payable.  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 anesthesia services provided to the enrollee on 
January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the arthrocentesis, aspiration and/or 
injection, of a major joint or bursa (20610 x 3) and the Hyaluronan or derivative, gelsyn-3, for intra-articular 
injection (J7328 x 3) provided from December 7, 2021, through December 21, 2021. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to 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 20% 
coinsurance for Medicare Part B covered drugs. Additionally, you must pay a $20 copayment for provider and 
professional services rendered at a specialists office.   
You have been asked to pay $483.36 ($423.36 + $60). This amount includes the Plans allowed amount of 
$705.60 x 20% coinsurance=$141.12 x 3=$423.36 for the Medicare Part B covered drug injections provided. 
Additionally, this amount includes a $20 copayment x 3=$60 for the provider and professional services 
rendered at a specialists office. 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 cost share for the arthrocentesis, aspiration 
and/or injection, of a major joint or bursa (20610 x 3) and the Hyaluronan or derivative, gelsyn-3, for  
intra-articular injection (J7328 x 3) provided from December 7, 2021, through December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast removal surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve breast removal surgery. You say that your breast implants are 19 years old, 
and about 3 to 4 years ago, you began to have breast pain. You also say that both breasts were sore, tender, and 
your breasts hurt when hugging, reaching, bending, and sleeping. The Plan denied your request. The Plan says 
the member is requesting an out of plan referral to a plastic surgeon for bilateral breast implant removal, which 
the Plan has denied because it is not medically necessary at this time. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 breast removal surgery. Our reviewer says that this does not meet criteria. 
Our physician reviewer found in this case, the record provided does not indicated that the enrollee has rupture of the implants, capsular contracture, or systemic disease manifestations that establish the medical necessity of 
implant removal. Our doctor also found the record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, or the requested service, and 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 breast removal surgery have not been met.  
 
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 breast removal surgery. Therefore, we decided that the 
Plan does not have to pre-approve breast removal surgery to be provided by an out-of-network (OON) 
provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 PT visits. You say that the additional visits are medically necessary. The 
Plan denied your request. The Plan says the additional 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 10 PT 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 the provided records indicate that the enrollee has had prior therapy. 
The reviewer found that the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a convergent hybrid ablation procedure. 
 
You asked the Plan to pre-approve a convergent hybrid ablation procedure. You say that the records provided 
support the need for cardiac ablation services. The Plan denied your request. The Plan says that the requested 
procedure is not medically necessary. 
 
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 a convergent hybrid ablation procedure. 
Our reviewer says that the requested services are considered medically reasonable and necessary in this case. 
Our physician reviewer found at issue is the appropriateness and medical necessity of performing a convergent 
hybrid ablation procedure in a patient with longstanding persistent atrial fibrillation. The request is for 
authorization of the performance, not of the stand-alone, surgical MAZE procedure. The CONVERGE trial 
demonstrated the superiority of this hybrid approach combining epicardial and endocardial ablation compared 
with an endocardial catheter ablation procedure alone. While the simpler endocardial catheter ablation 
procedure would be more appropriate for paroxysmal atrial fibrillation, proceeding directly to a convergent 
hybrid procedure would be acceptable because of the poor results of endocardial catheter ablation alone, with 
the frequent need to later carry out a convergent hybrid procedure. As a result, authorization for the 
performance of a convergent hybrid ablation procedure would be considered appropriate and reasonable in this 
patient's clinical management. 
 
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 convergent hybrid ablation procedure have been met. Therefore, we decided 
that the Plan has to pre-approve a convergent hybrid ablation procedure.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing provided on November 8, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this testing is a standard of practice. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not 
coded appropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single procedure code shall be reported.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic panel testing provided on November 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the complete bilateral noninvasive 
physiologic studies of the upper or lower extremity arteries (93923) and the duplex scan of the lower extremity 
arteries or arterial bypass grafts; complete bilateral study (93925) provided on November 16, 2021 and 
November 17, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $45 copayment for diagnostic procedures and tests.  
 The enrollee has been asked to pay $90 ($45 copayment x 2) for the diagnostic tests provided. 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 copayments for the complete bilateral noninvasive physiologic studies of the upper 
or lower extremity arteries (93923) and the duplex scan of the lower extremity arteries or arterial bypass grafts; 
complete bilateral study (93925) provided on November 16, 2021 and November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient psychiatric hospital services 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee's mental 
state is not stable as they are paranoid and delusional. The Plan denied your request. The Plan says that the 
enrollee's condition has improved and is no longer an imminent threat to themselves or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are medically necessary to improve the patients 
condition. Our physician reviewer found that the enrollee does meet the criteria for treatment in an acute 
inpatient mental health facility and could not have been treated in a lesser restrictive setting as he was not 
showing any suicidal or homicidal ideation, auditory or visual hallucinations, but the enrollee was showing 
aggressive and violent behavior. 
 
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 psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve continued inpatient psychiatric hospital services  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the office visits provided on April 27, 
2021 and May 25, 2021. 
 
You asked the Plan to waive the coinsurance for the office visits. You say that you are requesting 
reimbursement for services rendered at the provider. The Plan denied your request. The Plan says you have 
been charged the correct coinsurance 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 30% 
coinsurance for specialist's office visit.  
 
 
 
 
 
 You have been asked to pay $73.84, which is 30% of the allowed amount for the office visits. The allowed 
amount is $123.07 per visit (30% x $123.07 = $36.92). The office visits fall within the Physician/Practitioner 
services, including doctors office visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the office visits provided on April 27, 2021 and May 25, 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF is not medically necessary and the enrollee's ongoing skilled therapy 
and nursing needs can be provided at a lower level of care such as at a skilled nursing facility, on an 
intermittent basis at home with home health care, or in a long-term care setting. 
 
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 that while the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional surgical services provided to the enrollee on 
November 16, 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 documentation does not support that additional services were completed. 
 
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 36561: 
 
Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or 
older 
 
CPT 77001: 
 
Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or 
removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast 
injections through access site or catheter with related venography radiologic supervision and interpretation, and 
radiographic documentation of final catheter position) (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 
 
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 provider was paid for CPT codes 
36561, 77001-26 and 99152 per claim 88160673-00/NYC, with billed ICD-10 code Z45.2, however the 
documentation does not support additional services. The records do not support that these codes were rendered 
more than once. 
 
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 additional surgical services provided to the enrollee on November 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880). 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. You say that you would like a carotid 
duplex done on the enrollee due to dizziness and high blood sugar for about a month and a half. You also say 
that the enrollee wants to make sure their carotid arteries are alright. The Plan denied your request. The Plan 
says this request for a duplex scan of the extracranial arteries is not sufficiently supported. 
 
The Plan follows Medicare rules. Medicare rules say that testing methods that include (real-time) duplex scans 
and Doppler ultrasound waveform with spectral analysis are covered for the indications listed in the Medicare 
rules section above. 
 
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 duplex scan of extracranial arteries. 
Our reviewer says that at this time cardiac doppler imaging would not be considered medically appropriate and 
necessary in this patients clinical management. Our physician reviewer found there is no reference to 
abnormal carotid pulses or bruits. Our reviewer found that the documentation does not support the rationale for 
this imaging study. Our physician reviewer also found that the guidelines do not support a need for carotid 
duplex scan extracranial bilateral study (93880). 
 
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 duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says the provider is not 
contracted with the health Plan. The member does not have out of network benefits. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on January 26, 2022.