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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee's needs are met in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient does not require services at the LTACH that are not already available at 
the current facility. Transfer would not be clinically advantageous at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to make additional payment for infusion services. We decided that the Plan does not have to fully pay for infusion services.

You asked the Plan to pay for infusion services. You say that you should be reimbursed for these services. The Plan says that the denial of additional payment for these services is correct, because you have been reimbursed up to the Medicare allowed amount for these services and the Plan is not responsible for payment beyond this amount.

We decided that the Plan has to make additional payment for the infusion services.

The Plan follows Medicare rules. Medicare rules state that the allowed payment amount of infusion service code 96365 is $74.12 for dates of service in 2021 and $69.68 for dates of service in 2022. There were infusion service visits in 2021, resulting in an allowable payment amount of $370.60. There were infusion service visits in 2022, resulting in an allowable payment amount of $487.76. Therefore, the total reimbursement amount should be $858.36.

We looked at Medicare rules and the file. The Plan only issued a payment amount of $815.45. Therefore, we decided that the Plan has to pay an additional $42.91, to result in a total reimbursement amount of $858.36 for infusion services.

We also decided that the Plan does not have to fully pay for infusion services.

The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the enrollee.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infusion services have not been met. Specifically, once the plan reimburses you an additional $42.91 the Plan will have paid the Medicare Allowed Amount for these services. A Medicare provider should accept the Medicare Allowed Amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare allowed payment. Therefore, we decided that the Plan does not have to fully pay for infusion 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: 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 you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting do not meet the requirements for approval. 
 
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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patients medical conditions are stable on outpatient medications with no 
issues that appear to require a physicians evaluation three or more times per week. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet block injections. 
 
You asked the Plan to pre-approve facet block injections. 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 follows Medicare rules. Medicare rules say that diagnostic facet joint procedures are covered when 
specific criteria are met. 
 
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 facet block injections. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the coding request is for 
thoracic facet blocks and not L3-L4 MBBs as suggested by the progress notes. Since there was minimal relief 
from the last set of thoracic MBBs, these should not be repeated. The request is not medically reasonable or 
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 facet block injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet block injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning services (procedure code 99497) 
provided to the enrollee on June 25, 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 this service was not documented as performed. 
 
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 99497 is "Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate." 
 
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 the documentation submitted did 
not include any record of the billed code. The review has determined that the records do not support that CPT 99497 was rendered in this case. 
 
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 advance care planning services (procedure code 99497) provided to the enrollee on June 25, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive one of the copayments for a spinal injection performed on 
February 22, 2022, and a nerve destruction procedure performed on March 15, 2022. 
 
You asked the Plan to waive one of the copayments for the injection and nerve destruction. You say that you 
should only have to pay one copayment for both procedures. 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 $150 
copayment per visit to an outpatient hospital facility.  
 
You have been asked to pay a $150 copayment each for the injection and nerve destruction, for a total of $300. 
The injection and nerve destruction fall within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers 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 one of the copayments for a spinal injection performed on February 22, 2022, and a nerve destruction 
procedure performed on March 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on August 21, 
2021. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that this copayment is too high, and that 
you cannot afford it. The Plan denied your request. The Plan says the copayment applied was 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 a $400 
copayment for Outpatient Surgical Services.  
 
You have been asked to pay a $400 copayment for an endoscopy. An endoscopy falls within the Outpatient 
Hospital Surgical 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 an 
endoscopy provided on August 21, 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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Provided records do not explain why the intensive inpatient rehabilitation 
therapy program is necessary and why therapy at a lower level of care such as in a skilled nursing facility is not 
appropriate for 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on October 22, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says Screening genetic testing is not a covered benefit. 
 
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 genetic testing provided on October 22, 2020, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records support completion of treatment at the current facility. Transfer would not 
be clinically advantageous at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care telehealth visit provided on 
February 7, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that the call only lasted 10 minutes 
and the provider told you to go to the ER. 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 $10 
copayment for each PCP visit, including telehealth services.  
 
You have been asked to pay a $10 copayment for the telehealth visit. The telehealth visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 copayment for a primary care telehealth visit provided on February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a neurostimulator implant procedure 
performed on December 28, 2021. 
 
You asked the Plan to reduce the copayment for the neurostimulator implant. You say that you were informed 
there would only be a $40 copayment. 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 $400 
copayment for surgery or services, other than a colonoscopy, at an ambulatory surgical center or outpatient 
hospital facility.  
 
You have been asked to pay a $400 copayment for the neurostimulator implant. The neurostimulator implant 
falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 reduce the copayment for a 
neurostimulator implant procedure performed on December 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdominal ultrasound provided on 
March 18, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that insurance should cover this 
procedure. 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 $125 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay $87.72, which is less than the $125 copayment for the ultrasound. The ultrasound 
falls 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 copayment for an abdominal ultrasound provided on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory/infusion services (36430, P9016) provided on 
February 24, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory/infusion services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory/infusion services (36430, P9016) 
provided on February 24, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revascularization services provided to the enrollee on 
October 29, 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 37224: 
 
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
transluminal angioplasty  
CPT 93042: 
 
Rhythm ECG, 1-3 leads; interpretation and report only 
 
In terms of CPT 37224, 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 available 
documentation does not support an open or percutaneous endovascular revascularization of a unilateral femoral 
or popliteal artery(s), with transluminal angioplasty (CPT 37224) on 10/29/21. 
 
In terms of CPT 93042, 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 93042 is a column II code to column I code 99291 with a modifier indicator of 0. The 
column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been 
met. 
 
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 revascularization services provided to the enrollee on October 29, 2021.