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

 
We decided that the Plan does not have to waive the copayment for the removal of a tension sheath lesion 
provided on June 28, 2023. 
 
You asked the Plan to waive the copayment for the removal of a tension sheath lesion. You say that you do not 
remember being sent a notice of changes made to your plan. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $370 
copayment per day for outpatient procedures and services, including outpatient surgery performed in an 
outpatient hospital. 
 You have been asked to pay a $370 copayment for the removal of a tension sheath lesion. This item/service 
falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 the removal of a tension sheath lesion provided on June 28, 
2023.
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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the 
IRF services requested 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 the enrollee is medically improving and does not need physical medicine and 
rehabilitation physicians supervision 3 times a week in an IRF. At the current functional level, the enrollee, 
with low activity tolerance will not make a significant functional recovery in a short-term acute rehabilitation 
facility and does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach in an IRF. The enrollee needs physical therapy and occupational therapy. 
The document does not support necessity for admission to an IRF. The complexity of the enrollees medical, 
rehabilitatin, and nursing needs (combined complexity) does not require acute hospital inpatient rehabilitatin 
stay with an interdisciplinary approach to rehabilitative care. The enrollees rehabilitation needs can be safely 
provided in a low intensity alternate 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on 
August 14, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that the services should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home or residence visit 
for the evaluation provided on August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 18, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this service is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on July 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulator. 
 
You asked the Plan to pre-approve peripheral nerve stimulator. You say that peripheral nerve stimulator is 
medically necessary. The Plan denied your request. The Plan says medical studies have not proven this service 
is helpful for the treatment of your health problem. 
 
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 peripheral nerve stimulator. Our 
reviewer says that the requested peripheral nerve stimulator is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered experimental therapy. It is the subject of 
ongoing clinical trials. Additionally, the enrollee has not had physical therapy or additional evidence based 
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 peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve peripheral nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that prior authorization is not required for walk-in 
clinics. You also say that the medical records support that the service was medically necessary. The Plan 
denied your request. The Plan says 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 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 office visit provided on July 17, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 7, 2023. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on January 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service July 13, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99070 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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block (64454). 
 
You asked the Plan to pre-approve genicular nerve block. You say that the requested procedure is medically 
necessary to treat the enrollee. The Plan denied your request. The Plan says the procedure requested does not 
meet the criteria necessary for approval. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is morbidly obese and has bilateral knee pain. He underwent Saphenous, 
Obturator and genicular nerve blocks with hydrodissection and neuroplasty. This is considered experimental 
therapy. Therefore, the request is deemed not medically reasonable and 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block (64454).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 9, 2023. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the claim 
was billed with the incorrect modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that for ambulance service claims, institutional-based 
providers and suppliers must report an origin and destination modifier for each ambulance trip provided in 
HCPCS/Rates. 
 
We looked at the file and Medicare rules. In this case, the ambulance services were billed with modifier NP. 
The records do not support that the origin was a skilled nursing facility and the destination was a physician's 
office. As such, the billed modifier is inappropriate. Based on this information, we decided that Medicare rules 
for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for the ambulance services provided on August 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
August 15, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you disagree with 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for outpatient diagnostic tests/Medicare-coveredoutpatient diagnostic. 
 
You have been asked to pay a $175 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/Medicare-coveredoutpatient diagnostic 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. However, since the allowed amount is 
less than the standard copayment, you only owe $61.42. Therefore, we decided that the Plan does not have to 
waive the copayment for an outpatient diagnostic test provided on August 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on May 21, 2023, to May 
22, 2023. 
 
You asked the Plan to pay for the medication. You say that this should be paid for. The Plan denied your 
request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on May 21, 2023, to May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 20, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for OON practitioner services. You say that your facility is in the Plan's network. 
The Plan denied your request. The Plan says that their original decision to deny payment was correct. 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 practitioner services provided on September 20, 
2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 15, 
2023. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 
copayment for outpatient diagnostic tests/lab services. 
 
You have been asked to pay a $95 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic tests/lab 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 
laboratory services provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the repositioning of intraocular lens prosthesis, requiring an incision, 
coded as 66825 performed on date of service July 26, 2023. 
 
You asked the Plan to pay for 66825. You say that 66825 should be paid as billed because it is supported in the 
medical record and modifier -78 was appended. The Plan denied your request. The Plan says that 66825 is 
denied because the use of modifier -78 is not supported as a review of the enrollee's claim history does not 
indicate this was a subsequent procedure billed during the postoperative period of an initial procedure.  
 
The Plan must follow Medicare rules. Medicare rules say that physicians should report modifier -78 for a return 
trip to the operating room for a related procedure during a postoperative period.  
 
We looked at the file and Medicare rules. In this case, we confirmed that code 66825 was billed with modifier -
78. The records support that this enrollee did have an initial surgery on July 25, 2023, and records support that 
surgery was performed by the same provider who performed 66825. The records also support that the claim in 
question was for an unplanned return trip to the operating room that was related to the first procedure. Whether 
or not the claim for the initial surgery has been received yet is not sufficient to justify the denial of this service 
based on the modifier. The documentation still justifies this the use of modifier -78. Based on this information, 
we decided that Medicare rules for coverage of 66825 have been met. Therefore, we decided that the Plan has 
to pay for the repositioning of intraocular lens prosthesis, requiring an incision, coded as 66825 performed on 
date of service July 26, 2023.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a power operated vehicle, group 1 standard, patient weight 
capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says that you do not meet criteria for approval of the 
requested scooter. 
 
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. We sent the Plan a request for information asking for medical records. The 
medical records were not received. Therefore, we decided that the Plan has to pre-approve a power operated 
vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).  
 
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 the enrollee has a significant medical history for 
mild Parkinson's, hyperlipidemia, obstructive sleep apnea, and urinary retention. You also say that the medical 
records provided support the need for the requested IRF admission. The Plan denied your request. The Plan 
says based on the available information, admission to IRF is not reasonable and necessary, as the enrollee'ss 
condition does not meet the Medicare rules.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a fall and rhabdomyolysis. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.