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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 
13, 2023 to March 14, 2023. 
 You asked the Plan to pay for SNF care. You say that the enrollee needs this level of care. The Plan denied 
your request. The Plan says that admission to an SNF should have been preauthorized. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from February 13, 2023 to March 14, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324). 
 You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Durolane, 
Euflexxa, Synvisc, or Synvisc One. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orthovisc. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drug. The reviewer also found that there is no 
documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group psychotherapy services described by code 90853 
performed on date of service August 7, 2023.  
 
You asked the Plan to pay for 90853. You say that 90853 should be paid as billed because it is supported in the 
medical record. The Plan denied your request. The Plan says 90853 is denied because it was billed by an 
ineligible provider and the services were not documented and billed as incident to physician services.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that Physicians, Clinical 
Psychologists, Clinical Social Workers, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists are eligible to provide 
diagnostic and therapeutic mental health services, perform diagnostic tests, and provide BHI and SBIRT 
services as permitted under state law. 
 
We find that CPT code 90853 is not supported in the medical record. Specifically, we confirmed that 90853 
was not rendered by one of the eligible provider types. Records contain evidence that 90853 was rendered by a 
counselor. We confirmed that the services in this case were not billed as incident to physician's professional 
services with documentation of direct supervision by the physician. As such, the denial of 90853 is appropriate. 
Based on this information, we decided that Medicare rules for coverage of 90853 have not been met. Therefore, 
we decided that the Plan does not have to pay for the group psychotherapy services described by code 90853 
performed on date of service August 7, 2023.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's continued care needs include intravenous 
medications and wound care. The Plan says when the enrollee is ready to leave the hospital care may be 
provided in another 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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
September 19, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that the services should 
be covered. 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 $75 
copayment for outpatient diagnostic test/ultrasound. 
 
You have been asked to pay a $75 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic test/ultrasound 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 outpatient diagnostic test provided on September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97813, 97814) provided on  
April 25, 2023. 
 
 
 You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of the acupuncture services provided in this case.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for the acupuncture services (97813, 97814) provided on April 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on March 1, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the enrollee was evaluated in the emergency department (ED) for leg swelling. An appropriate history and 
physical were documented; However, the records do not support that the medical decision making was of high 
level. As such, the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on March 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of stent in groin artery, initial vessel (37221) 
and balloon dilation of groin artery, initial vessel (37220). 
 
You asked the Plan to pre-approve insertion of stent in groin artery, initial vessel and balloon dilation of groin 
artery, initial vessel. 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 the PTA is 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 insertion of stent in groin artery, initial 
vessel and balloon dilation of groin artery, initial vessel. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found the vascular findings do not satisfactorily correlate with your 
symptoms. You have numerous coexisting conditions that could limit your walking distance. The unilateral 
noninvasive vascular findings do not correlate with your severe bilateral walking limitation. The assessment is 
not supported by a physical pulse examination. The assessment and plan are for treatment of the right common iliac artery; however, the noninvasive studies specifically documented absence of iliac artery stenosis or 
occlusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of stent in groin artery, initial vessel and balloon dilation of groin 
artery, initial vessel have not been met. Therefore, we decided that the Plan does not have to pre-approve 
insertion of stent in groin artery, initial vessel (37221) and balloon dilation of groin artery, initial vessel 
(37220).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
October 11, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a routine 
screening colonoscopy and should not have a 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 $250 
copayment for each Medicare-covered surgical procedure, including a diagnostic colonoscopy.  
 
The medical records show you had polyps removed during the colonoscopy; therefore, this was a diagnostic 
procedure. You have been asked to pay a $250 copayment for the diagnostic colonoscopy. This item/service 
falls within the outpatient surgery 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 diagnostic colonoscopy provided on October 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient detoxification. 
 
You asked the Plan to pre-approve inpatient detoxification. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the request for an inpatient detoxification level of care 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 detoxification. 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 documentation states that the enrollee is appropriate for "outpatient treatment 
with no contraindications 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 inpatient detoxification have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient detoxification.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the rabies vaccine provided on July 27, 
2023. 
 
You asked the Plan to waive the coinsurance for the rabies vaccine. You say that you say that the service was 
medically necessary. 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 50% 
coinsurance for outpatient hospital services. 
 
You have been asked to pay 50% coinsurance for the rabies vaccine. This item/service falls within the 
outpatient hospital 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. The total you owe is $876.70 ($1,753.38 allowed amount x 50% = $876.70) Therefore, we 
decided that the Plan does not have to waive the coinsurance for the rabies vaccine provided on July 27, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 25, 2023, to 
August 29, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the enrollee did not meet medical necessity criteria for an 
inpatient stay. The care could have been provided at a lower level. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission it was reasonable for the admitting 
physician to expect that the patient's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights with supporting documentation of the patients history and 
comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 25, 2023, to August 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on August 17, 2023. 
 
You asked the Plan to pay for ophthalmological services. You say that the services were medically necessary. 
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 ophthalmological 
services provided on August 17, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for medical services provided out-of-area on July 24, 2023, and September 
6, 2023. 
 
You asked the Plan to pay for the medical services provided out-of-area. You say that the services provided 
were not routine. You say that the enrollee was out of the area when she experienced a urinary tract infection 
(UTI) and then when she fell and suffered 2 hairline fractures of the lower ribs.  The Plan denied your request. 
The Plan says that the services were provided out-of-network without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide us with any medical records or evidence of 
having made reasonable attempts to obtain medical records. Without this necessary information, we cannot 
review the appellants argument that the services provided were urgent in nature and the Plan has not 
substantiated their denial reason. Therefore, we decided that the Plan has to pay for medical services provided 
out-of-area on July 24, 2023, and September 6, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 23, 
2023.  You asked the Plan to pay for procedure code 88341. You say that the additional units were necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 28 units of this 
code, exceeding the MUE. The medical records do not provide rationale regarding why the excess units were 
needed to treat this specific enrollees condition. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 88341 billed for date of service February 23, 2023.