Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation treatment delivery provided on 
May 05, 2023. 
 
You asked the Plan to waive the coinsurance for radiation treatment delivery. You say that you were not aware 
that you had a coinsurance. 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 20% 
coinsurance for therapeutic radiology services. 
 
You have been asked to pay 20% coinsurance for radiation treatment delivery. This item/service falls within 
the therapeutic radiology 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 $44.86 ($224.28 allowed amount x 20% = $44.86 rounded 
up). Therefore, we decided that the Plan does not have to waive the coinsurance for radiation treatment delivery 
provided on May 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hereditary Hemochromatosis (HFE) genetic testing 
(81256). 
 You asked the Plan to pre-approve HFE genetic testing. 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 molecular pathology procedures may be eligible for 
coverage when all 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 HFE genetic testing. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the review indicates that the 
criteria for testing indicate a need of an iron overload of uncertain etiology and the ferritin, and the transferrin 
saturation need to be elevated greater than 45% of the normal range. Although the enrollee's ferritin level is 
elevated, it is not greater than the required 45% elevated. The review has determined that the enrollee does not 
meet the coverage criteria detailed 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 HFE genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hereditary Hemochromatosis (HFE) genetic testing (81256).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 clinical documentation shows that patient has had clinical status change; thus, 
would be expected to require assessment by skilled nursing. No functional status change specified; thus, would 
not be expected to require skilled therapy assessment. The clinical documentation does not specify any daily 
skilled nursing needs; thus, the medical necessity for daily skilled services is not supported. From a practical 
standpoint, clinical documentation does not support daily skilled services on an inpatient basis 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the non-emergency ambulance 
transportation provided on May 1, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you do not feel the 
trip was necessary to the emergency room. 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 $290 
copayment for non-emergency ambulance per date of service regardless of the number of trips.  
 
You have been asked to pay a $290 copayment for the ambulance transportation. This item/service falls within 
the ambulance 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 the non-
emergency ambulance transportation provided on May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent of the genicular nerve 
branches (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent of the genicular nerve branches. You say 
that you are requesting reconsideration with the goal of improving the enrollee's function, range of motion, 
mobility, pain, and decrease reliance on medications. The Plan denied your request. The Plan says the request 
does not meet the requirements 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 destruction by neurolytic agent of the 
genicular nerve branches. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/ 
investigational therapy. The role of radiofrequency ablation in treating chronic knee pain is the subject of 
ongoing clinical trials. 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 destruction by neurolytic agent of the genicular nerve branches have not been 
met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent of the 
genicular nerve branches (64624).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic testing services provided on March 6, 2023. 
 
You asked the Plan to pay for the services. You say that you would like this claim to be reprocessed. The Plan 
denied your request. The Plan says they do not have the information we need to consider this charge. 
 
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 pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found given the conflicting evidence to date and the overarching consensus that further study is necessary to evaluate the use of intraoperative neurophysiological monitoring (IONM) in lumbar spine surgery. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the diagnostic testing services provided on March 6, 2023.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 documentation does not support that this enrollee requires skilled nursing services 
with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively 
provide care only in a SNF. The enrollee does not have complex wound care, intravenous (IV) antibiotics, 
enteral feedings or other skilled nursing (SN) need during these dates that require a SNF admission. The 
enrollee's functional level does not require the skills of a professional therapist only in a SNF. The enrollee 
does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, this enrollee's needs 
do not require the necessary services on an inpatient basis in a SNF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87506) provided May 15, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this code is not supported for the services 
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, the CPT Code Manual definition of code 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 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 laboratory service. Our reviewer found the 
documentation submitted was reviewed and does not meet criteria. The laboratory report does not support 6-11 
targets. In this case, there is a more appropriate code to report for service provided.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (87506) provided May 15, 2022.
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 needs the requested level of care before 
returning home.  The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria 
for coverage of SNF care. 
 
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 at the time of admission, the enrollee required skilled rehabilitation services to 
improve function due to weakness and deconditioning.  There were no skilled nursing needs. As of the last 
covered day, the enrollee did not require any skilled nursing or rehabilitation services on a daily basis.  He was 
not expected to make measurable gains within a reasonable and predictable period of time or require skilled 
therapy to prevent deterioration with mobility or self-care tasks.  The enrollee did not require skilled therapy to 
establish a safe and effective maintenance program.  As a practical matter, the enrollee did not require any 
skilled services on an inpatient basis, at a skilled level of care as of September 17, 2023. 
The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube.  
The enrollees function was at or near his new baseline level of function and he could be discharged to a lower 
level of care for further services.  As of September 27, 2023, the enrollee required custodial services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 you cannot be managed at a lower level 
of care and risks further deterioration if not approved for LTACH. The Plan denied your request. The Plan says 
the stay is not medically necessary based on LTACH criteria.  
 
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 you are receiving appropriate care in current acute care setting as provided by the 
Health Plan. The documentation does not support that LTACH services are medically appropriate 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapist. 
 
You asked the Plan to pre-approve these services. You say that you need more physical therapy after back 
surgery. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network physical therapist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 21, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.  
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96401 rendered on June 20, 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 denied code is 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 96401 is "Chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic." 
 
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 records do not include a 
procedure for chemotherapy administration, subcutaneous or intramuscular, non-hormonal anti-neoplastic. The records include an evaluation and management service, with no injection services provided. 
 
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 96401 rendered on June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93228 and 93229 rendered on June 6, 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 support the services billed. 
 
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 the denied codes is: 
 
CPT 93228: 
 
External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real 
time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG 
triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional 
 
CPT 93229: 
 
External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real 
time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG 
triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; 
technical support for connection and patient instructions for use, attended surveillance, analysis and 
transmission of daily and emergent data reports as prescribed by a physician or other qualified health care 
professional 
 
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 records do not support CPT 
93228 or CPT 93229. The records do not include interpretation and report, as well as a physician order for the 
procedures reported. The report does not include documentation of connection and patient instruction. 
 
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 codes 93228 and 93229 rendered on June 6, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injection services. 
 
You asked the Plan to pre-approve the facet joint injection services. You say that the enrollee is in severe pain 
and hopes this will help. The Plan denied your request. The Plan says that the requested services are not 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that facet joint injection services are considered 
medically reasonable and necessary for certain indications and when specific criteria for coverage have been 
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 facet joint injection services. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has been doing a home exercise program for greater than 3-months and 
has failed conservative 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 the facet joint injection services have been met. Therefore, we decided that the 
Plan has to pre-approve facet joint injection services.  
 
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.