Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 81272, 81209, and 81218. 
We decided that the Plan does not have to pay for the services described by procedure codes 81162, 81201, 
81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81334.  
 
You asked the Plan to pay for 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81334, 
81272, 81209, and 81218 for date of service July 7, 2023. You say that you disagree with the Plan's denial. The 
Plan says that the services are not payable as billed. 
 
We decided that the Plan has to pay for the services described by procedure codes 81272, 81209, and 
81218.  
 
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 make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 81272, 81209, and 81218.  
 
We also decided that the Plan does not have to pay for the services described by procedure codes 81162, 
81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81334. 
 
The Plan follows Medicare rules. Medicare rules say that for molecular diagnostic tests, such as the test at 
issue, the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 
81321, 81351, and 81334 have not been met. Therefore, we decided that the Plan does not have to pay for the 
services described by procedure codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 
81334. 
 
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 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 enrolleer's 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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is 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, but the services required can be provided at a lower level of 
care.  
 
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 pre-approve radiofrequency ablations (64636, 64635). 
 
You asked the Plan to pre-approve radiofrequency ablations. You say that you would like two units for 64635 
and 2 units for 64636 to be approved instead of the three levels you had previously submitted for. The Plan 
denied your request. The Plan says the radiofrequency ablations are not medically necessary. 
 
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 radiofrequency ablations. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of lumbarspondylosis without radiculopathy. She has 
trialed non-steroidal anti- inflammatory drugs (NSAIDs) in the past for her pain. The LCD criteria is 
documentation of 2 sets of diagnostic MBBs that produce at least 80% pain relief.  Only the first set is 
documented at 80%. The LCD has a utilization limit of 2 levels bilaterally of RFA per session. The request 
exceeds this limit and there is no extraordinary circumstance that is documented to exceed that limit. 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 radiofrequency ablations have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablations (64636, 64635).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0110 and D0120) on September 7, 
2023. 
 
You asked the Plan to pay for the dental services (D0110 and D0120). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services (D0110 and D0120) on September 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on June 28, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an OON provider on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99211-25 performed on date of service September 25, 2023. 
 
You asked the Plan to pay for 99211-25. You say that 99211-25 should be paid as billed because modifier -25 
was appended, and Medicare has paid for this code when billed with 36415 in the past. The Plan denied your 
request. The Plan says 99211-25 is denied because records do not support that this was a significant and 
separately identifiable evaluation and management service unrelated to code 36415 billed on the same date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 99211-25. Our reviewer says that 99211-25 is not supported in the documentation. Our reviewer found that the medical records provided do not include sufficient 
documentation to validate that the evaluation and management service 99211 was a significant and separately 
identifiable service from other services performed and reported on the same date. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99211-25 have not been met. Therefore, we decided that the Plan does not have 
to pay for the evaluation and management services described by code 99211-25 performed on date of service 
September 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray provided on September 13, 
2023. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that nobody told you about the 
copayment and you should not have to pay it. 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 $50 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $50 copayment for the chest x-ray. This item/service falls within the outpatient diagnostic tests 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 chest x-ray provided on 
September 13, 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 you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says it is not medically necessary for the enrollee to go 
to an IRF.  
 
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 your nursing, medical, and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy in an intensive 
rehabilitation therapy program. Medically necessary care can be provided in a different level of care. There is 
no reasonable expectation that you 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 14, 2023. 
 
You asked the Plan to pay for home health services. You say that this was medically necessary and 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 home health services 
provided on March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography provided on October 04, 2023. 
 
You asked the Plan to pay for the fundus photography. You say that you are asking for the review of the 
medical 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 the fundus photography 
provided on October 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99307 rendered on August 17, 2023. 
 
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 visit was for wound care assessment and evaluation. 
 
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 99307 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and straightforward medical decision making. When using total time on the date of the encounter for code 
selection, 10 minutes must be met or exceeded." 
 
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 supported by the medical records. Our reviewer found that the medical records describe an 
assessment and wound care on the buttock. In this case, a significant, separately identifiable evaluation and 
management service was not found in medical record and cannot be verified. When a significant and separately 
identifiable E&M and a procedure are both performed, the documentation of the encounter must clearly reflect 
two separate services with no overlap in work between the E&M and the procedure. The documentation must 
explain what work was associated with the E&M and separately explain what work was associated with the 
procedure, with a clear distinction that there was no overlap between the two. 
 
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 procedure code 99307 rendered on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308-25 rendered on August 21, 2023. 
 
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 clinical information shows that CPT 99308 was directly related to the wound care 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. 
 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 procedure report describes 
assessment and care of wound.  In this case, a separately identifiable evaluation and management service was 
not included in documentation submitted for review. 
 
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 procedure code 99308-25 rendered on August 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 rendered on August 14, 2023. 
 
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 records do not show two different physicians performed an abdominal x-ray with a single 
review. 
 
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 74018 is "Radiologic examination, abdomen; 1 view." 
 
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 in this case, the modifier billed 
cannot be verified. The medical records include a computed tomography (CT) scan of the abdomen/pelvis without contract, upper gastrointestinal single contrast, and x-ray of the abdomen, one view. A repeat abdomen 
x-ray, one view was not found in the records. 
 
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 procedure code 74018 rendered on August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VivAer for treatment of nasal airway obstruction. 
 
You asked the Plan to pre-approve VivAer for treatment of nasal airway obstruction. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says this is considered 
as experimental or investigational. 
 
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 VivAer for treatment of nasal airway 
obstruction. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record indicates that the enrollee has inferior turbinate 
hypertrophy causing nasal obstruction. There is insufficient literature to support the safety and efficacy of the 
requested service for the enrollee's specific conditions. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VivAer for treatment of nasal airway obstruction have not been met. Therefore, 
we decided that the Plan does not have to pre-approve VivAer for treatment of nasal airway obstruction.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from June 
11, 2023, to July 10, 2023. 
 You asked the Plan to pay for the SNF care. You say that the services should be covered under the Medicare 
Act. The Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay from 
June 11, 2023, to July 10, 2023. 
 
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 the 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 did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from June 11, 2023, to July 10, 2023.