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

 
We decided that the Plan does not have to pay for the lab services provided on October 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88271 and 88275 billed for date of service 
January 6, 2022. 
 
You asked the Plan to pay for procedure codes 88271 and 88275. The Plan denied your request. The Plan says 
payment for codes 88271 and 88275 is bundled into payment for code 88377.  
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 codes 
88271 and 88275 are column II codes to column I code 88377. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 88271 and 88275 billed for 
date of service January 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denied LTACH 
services. The Plan denied your request. The Plan says the documentation does not show that it is yet safe for 
the enrollee to leave the hospital. When the enrollee is ready to leave the hospital, they can safely receive this 
care in another setting, such as a skilled nursing facility or at home with home health services. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary at this time as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a posture corrector, BioFreeze Cool the Pain and an ankle 
compression sleeve provided on March 15, 2022. 
 
You asked the Plan to pay for a posture corrector, BioFreeze Cool the Pain and an ankle compression sleeve. 
You say that a representative of the Plan led you to believe the items at issue are covered. The Plan denied your 
request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of a posture corrector, BioFreeze Cool 
the Pain and an ankle compression sleeve provided on March 15, 2022, have been met. Specifically, no 
documentation is evident in the case record that a physician prescribed the items at issue for your use. 
Therefore, we decided that the Plan does not have to pay for a posture corrector, BioFreeze Cool the Pain and 
an ankle compression sleeve provided on March 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
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 you do not have coverage with the Plan. 
 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 
SNF services are not medically reasonable and necessary. The enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued 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 continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fact joint injections. 
 
You asked the Plan to pre-approve fact joint injections. You say that fact joint injections are medically 
necessary. The Plan denied your request. The Plan says under Medicare guidelines, your request is not 
medically necessary because the records do not show that the enrollee has had any form of therapy such as 
physical therapy, chiropractic care, massage or acupuncture. In addition, the record does not document a 
consistent positive response of at least 80% relief of primary (index) pain using an acceptable pain scale after 
the first injection on April 2, 2022. 
 
The Plan follows Medicare rules. Medicare rules say that  
 
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 fact joint injections. Our reviewer says 
that fact joint injections are not medically necessary. Our physician reviewer found this procedure is not 
medically necessary because there is no documentation of conservative therapy such as physical therapy, 
chiropractic care, massage or acupuncture. Also, there is no documentation of pain relief from the first set of 
MBBs of at least 80% relief of primary (index) pain using an acceptable pain scale after your first injection on 
April 2, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fact joint injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve fact joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrocentesis, aspiration and/or injection, major 
joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance, (code 20610) and 
Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg, (code J7325). 
 
You asked the Plan to pre-approve an arthrocentesis, aspiration and/or injection, major joint or bursa  
(e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance, and Hyaluronan or derivative, 
Synvisc or Synvisc-One, for intra-articular injection, 1 mg. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says the injections do not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 arthrocentesis, aspiration and/or 
injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance, and 
Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found in this case, the records 
show that the enrollee did not have significant improvement in pain and functional capacity from the prior 
series of injections. The documentation states, "it worked a little bit."  The review has determined that the 
requested injections do not meet the Medicare LCD coverage criteria. 
 
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 arthrocentesis, aspiration and/or injection, major joint or bursa  
(e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance, and Hyaluronan or derivative, 
Synvisc or Synvisc-One, for intra-articular injection, 1 mg have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an arthrocentesis, aspiration and/or injection, major joint or bursa 
(e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance, (code 20610) and Hyaluronan or 
derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg, (code J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 4, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee does not need to stay in medical unit 
anymore and they need to start physical therapy and occupational therapy. The Plan denied your request. The 
Plan says the documentation does not show the enrollee needs to be seen by a rehabilitation doctor at least 3 
times a week for evaluation of functional and medical goals and progress. The services the enrollee needs can 
be provided safely in other settings like a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
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 the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. At the high current functional level, the enrollee does not need 3 hours a day 5 days a week of 
therapies. 
 
The lack of medical complexity and lack of nursing needs and high functional mobility do not support an acute 
hospital inpatient rehabilitation admission with an interdisciplinary approach to rehabilitation care. Document 
does not support the medical necessity for admission to an IRF. The enrollee's rehabilitation needs can be 
safely provided in an alternate and low intensity setting such as in a skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is medically necessary for the enrollee. Further, 
the uses of the ultrasound in IF-SRT will allow you to track the progress of treatment and adjust the course of 
treatment, if necessary, which can lead to fewer side effects and a better outcome. The Plan denied your 
request. The Plan says IGRT with ultrasound is not medically necessary in this case. There is no clinical 
guideline or standard which indicates a benefit to the use of ultrasound as IGRT for superficial radiation to a 
skin cancer of the nose. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found usually IGRT is used when critical structures are abutting or in close proximity to the target 
that is being treated to high doses. This situation does not apply to the enrollee for which the target lesion can 
be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable, but to 
bill for daily simple simulations and/or IGRT for a technology for which need has not been established by 
published data or supported by consensus guidelines (many of which recommend against treatment with these 
devices in general), my decision is unfavorable. Billing for daily simulations or IGRT would not be furnished 
in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on January 27, 
2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you went to this in-network 
provider for an eye exam for glasses, which is supposed to be paid in full per your policy. The Plan denied your 
request. The Plan says this claim processed correctly as billed. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for the 
diagnoses of Myopia, bilateral, Vitreous degeneration, bilateral, and Drusen (degenerative) of macula, bilateral. 
Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. 
Therefore, we decided that the Plan does not have to waive the copayment for the eye exam provided on 
January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3000) provided on February 23, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that the Plan's denial is erroneous. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000) provided on 
February 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service December 
21, 2020, to December 29, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says procedure 
code 99072 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 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 
procedure code 99072 billed for date of service December 21, 2020, to December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair provided on February 9, 2022. You asked the Plan to pay for the services provided. You say that you cannot walk or stand much at all. The 
Plan denied your request. The Plan says the device has features primarily for convenient use outside of the 
home. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device is only covered under certain 
medical indications.  
 
We looked at the file and the rules. The records do not show that you have a limitation of mobility related 
activities of daily living in the home. The records also do not include a home evaluation. Based on this 
information, we decided that the Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pay for the power wheelchair provided on February 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) care on 
October 01, 2021, to October 15, 2021. 
 
You asked the Plan to waive the copayment for Skilled Nursing Facility (SNF) care. You say that the enrollee 
is appealing the cost share bill because they were told by the plan that nothing else was owed. The Plan denied 
your request. The Plan says the cost sharing you are being charged is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $184 copayment for Skilled Nursing Facility (SNF) Care. $0 copayment each day for days 1 to 20. 
$184 copayment each day for days 21 to 57. $0 copayment for additional Medicare-covered days, up to 100 
days. There were 14 days, resulting in the amount of $2,576. Therefore, results in the total cost sharing amount 
of $2,576.  
 
 The enrollee has been asked to pay a $184 copayment for each day for days 21 to 57 for Skilled Nursing 
Facility (SNF) care. Skilled Nursing Facility (SNF) care falls within the Skilled Nursing Facility (SNF) Care 
benefit category. 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 copayment for Skilled Nursing Facility (SNF) 
care on October 01, 2021, to October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you believe that LTACH services is the 
most appropriate level of care for the enrollee. The Plan denied your request. The Plan says the documentation 
does not show that it is yet safe for the enrollee to leave the hospital. When the enrollee is ready to leave the 
hospital, they can safely receive this care in another setting, such as a skilled nursing facility or at home with 
home health services. 
 
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 that the enrollee appears to be somewhat unstable and requires short-term additional 
acute care services that can safely be administered at the current facility until more stable and appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. 
 There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary at this time as the enrollee is not yet stable for 
transfer and as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended. 
 
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 the LTACH services.