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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is needing SNF care to assist with their 
ambulating because the member was recently found on the floor unconscious, and their glucose was elevated. 
The Plan denied your request. The Plan says the skilled nursing facility (SNF) services requested do not meet 
the requirements for approval. 
 
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 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections (27096).   
 
You asked the Plan to pre-approve the injections. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
sacroiliac joint injections.   
  
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections will be considered 
medically reasonable and necessary when all of the requirements 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 the injections. Our reviewer says that 
the enrollee does not meet criteria for coverage of sacroiliac joint injections. Our physician reviewer found that 
in this case, there is no evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease. There 
are not at least three positive exam findings of sacroiliac joint dysfunction present on physical exam such as: 
Patrick's test, thigh thrust, Sacroiliac joint compression test, Yeoman's test, or Gaenslan's test. The review has 
determined that the enrollee does not meet the criteria indicated in the LCD. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint injections (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2023. 
 
You asked the Plan to pay for an office visit. You say that no authorization is required. 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 an office visit provided 
on May 24, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Synvisc. 
 You asked the Plan to pre-approve Synvisc. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Orthovisc or Supartz FX before it will approve 
Synvisc. 
 
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 Synvisc. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Synvisc. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Orthovisc or Supartz FX. The record does not 
show that these drugs would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Synvisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 52000 and 49580 billed for date of service 
November 15, 2022. 
 You asked the Plan to pay for procedure codes 52000 and 49580. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says payment for code 52000 
is bundled into payment for code 57425. Code 49580 is not supported in the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 52000 is a column II code to column I code 57425. This claim has 
not been billed with an appropriate modifier to bypass the edit. In addition, the CPT Code Manual definition of 
code 49580 is repair umbilical hernia, younger than age 5 years; reducible. We find that CPT code 49580 is not 
supported in the medical record. Specifically, the enrollee is not younger than age 5 years. Based on the claim 
submitted, Medicare billing criteria have not been met for codes 52000 and 49580. Therefore, we decided that 
the Plan does not have to pay for procedure codes 52000 and 49580 billed for date of service November 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 provided on March 22, 2023. 
 
You asked the Plan to pay for procedure code 99213-25. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. 
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 13151 
provided on March 22, 2023. The documentation submitted does not support a significant, separately 
identifiable evaluation and management service to support the use of the -25 modifier. Therefore, we decided 
that the Plan does not have to pay for procedure code 99213-25 provided on March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 8, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 17, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#30. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the dental records document the presence of extensive decay, and the long-term prognosis of the 
endodontic procedure's success is questionable. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 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 dental services. Our reviewer says 
that the crown and core buildup are not medically necessary. Our physician reviewer found that the 
documentation indicates that the root canal fillings are short of the radiographic apices of both roots by a 
significant margin. The coronal breakdown of tooth #30 is significant. Prior to the approval of a core buildup 
and crown the root canal should be evaluated for retreatment and due to the significant breakdown of the 
coronal structures if restoration is possible. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth #30.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity-Modulated Radiation Therapy (IMRT) 
(77014x10). 
 
You asked the Plan to pre-approve IMRT. You say that the enrollee has metastatic prostate cancer, and it has 
moved to his spine and causing severe pain. He has several organs at risk that is putting his life in jeopardy, and 
he is needing more therapy to help with this. The Plan denied your request. The Plan says medical studies have 
not shown that this is the best treatment for the enrollee's specific condition. 
 
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 IMRT. 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 being offered palliative radiation to a spine metastasis. IMRT for bone 
metastases is uncommonly needed for the palliative treatment. For this case, there is no dosimetric rationale for 
IMRT or plausible explanation for why IMRT would be needed over 2D or 3D radiation. It is the reviewer's 
opinion that IMRT can be considered medically necessary (even for palliation and/or non-standard indications) 
when justified by quantitative dose measures- when the dose-volume exposure of critical structures in 
unacceptable without IMRT. For this case, the need for IMRT is not justified based upon quantifiable 
dosimetric measures or a plausible rationale American Society for Therapeutic Radiology and Oncology 
(ASTRO) model policy emphasizes the need to support IMRT with dosimetry; this would be of particular 
importance for clinical scenarios for which IMRT is not considered standard. The decision is unfavorable for 
this case as IMRT 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 IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity-Modulated Radiation Therapy (IMRT) (77014x10).
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 an expedited appeal for the denial 
of acute inpatient rehabilitation services. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare guidelines for services in 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 the enrollees medical, rehabilitation and nursing needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. The enrollees 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99204-25) provided on June 13, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99204 is "Office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and moderate level of medical decision making. 
When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter". 
 
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 use of code 99204 
with modifier 25 is supported by the records provided. Our reviewer found that the enrollee is a new patient to 
the practice and/or doctor, and they performed an electromyography (EMG) in clinic, which supports the use of 
modifier 25. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the services (99204-25) provided on June 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minuteman device (22612). 
 
You asked the Plan to pre-approve a minuteman device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a minuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman device is experimental. More research is needed to show safety and 
efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a minuteman device (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on May 31, 2023. 
 
You asked the Plan to pay for physician services. You say that it is 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 physician services 
provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service December 2, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this service was medically necessary. The 
Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service December 2, 2022, billed 
with code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth provided on May 22, 2023. 
 
You asked the Plan to waive the copayment for telehealth. You say that you are requesting reconsideration for 
the denied claim. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for telehealth. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for telehealth provided on May 22, 2023.