Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (77014,
G6002).
You asked the Plan to pre-approve the IGRT. You say that the IGRT is medically necessary. The Plan denied
your request. The Plan says the requested service is 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 the IGRT. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found IGRT for whole breast radiation is an accepted standard only for exceptional circumstances such as
difficult patient set-up, prior radiation necessitating more accurate localization or abutment of the field against
a critical organ (such as heart in left sided breast cancers). Routine use of IGRT is not within accepted
standards or care, and no rationale was provided for the need of IGRT in the consult note or other
documentation.
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 IGRT have not been met. Therefore, we decided that the Plan does not have
to pre-approve Image Guided Radiation Therapy (IGRT) (77014, G6002). Please note the record shows the
plan has already approved Radiation Therapy for Breast Cancer Initial Phase: 16 fractions (treatment sessions)
of 3D conformal.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 22, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an
independent laboratory; however, the file shows that the specimen was obtained in an outpatient rehab facility
and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to pay for the
drug testing rendered on July 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on March 3, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you were told that you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $100 copayment for diagnostic radiology services. You have been asked to pay a $100 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a CT scan provided on March 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing care provided on February 20, 2020.You asked the Plan to pay for the skilled nursing care. The Plan denied your request. The Plan says services received from a non-plan doctor, hospital, or other health care provider without getting approval from our plan will not be covered.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay for skilled nursing care provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation with field of
view of both jaws provided on April 16, 2020.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that it was medically
necessary to have had this scan done to make sure that you had no infections before your surgery. The Plan
denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone
beam CT capture and interpretation with field of view of both jaws provided on April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing provided on January 7, 2020.
You asked the Plan to pay for neuromuscular junction testing. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because
this service is not covered by Medicare for the diagnosis codes billed.
The Plan must follow Medicare rules. Medicare rules say that procedure code 95937 is only covered when
billed with certain, specific diagnosis codes. Diagnosis codes M48.062 and M48.07 are not among those for
which procedure code 95937 is covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not
have to pay for neuromuscular junction testing provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 1, 2018 by a
non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-network provider without prior authorization.
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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on November 1,
2018 by a non-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 physical therapy home health services.
You asked the Plan to pre-approve physical therapy home health services. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 physical therapy home health services.
Our reviewer says that the documentation does not support that the requested home health services are
medically reasonable or necessary. Our physician reviewer found you were independent for sit to stand,
standing to lying, and ascending stairs. You required stand-by assistance to walk 250 feet with a wheeled
walker. You have been trained on a home exercise program. Services do not need to safely and effectively be
performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a
maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required
to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further
deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the semi-electric hospital bed. You say that this hospital bed is necessary.
The Plan denied your request. The Plan says the documentation does not support the need for a semi-electric
bed. A fixed or variable height hospital bed could be approved if requested.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the above noted 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 the semi-electric hospital bed. Our
reviewer says that the semi-electric hospital bed requested is not shown to be reasonable and necessary. Our
physician reviewer found the patient in this case is a 67-year-old male diagnosed with bladder cancer who is
requesting a semi-electric hospital bed. The prescribing physician wants the patient to have a fixed height bed
and the ability for the head of the bed to be elevated to allow for his ostomy bag to drain properly and to allow
for better positioning of his body. The provided records did not suggest the patient needed frequent adjustments
of position to justify a semi-electric hospital bed. A manual fixed or adjustable bed should suffice for his needs,
whereas, a semi-electric hospital bed was not justified in the notes and will be considered 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 semi-electric hospital bed have not been met. Therefore, we decided that the
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided on January 21,
2020.
You asked the Plan to waive the coinsurance for genetic testing. You say that you disagree with the charges.
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the
correct amount.
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 genetic testing.
You received genetic testing on January 21, 202. The total allowed amount is $535.88 and 20% of that is
$107.18.
You have been asked to pay the total coinsurance amount of $107.18 for genetic testing. Genetic testing falls
within the outpatient diagnostic tests and therapeutic services and supplies 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 coinsurance for genetic testing provided on January 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee replacement surgery at the inpatient level of care for the enrollee.You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary.The Plan denied your request. The Plan says this has been approved at the hospital but at the observation level of care.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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is indicated for right total knee replacement. The provider has requested inpatient admission indicating that patients generally do better with inpatient management, including physical therapy, occupational therapy, and pain management. Thereis no specific medical comorbidity reported by the provider to support the medical necessity of inpatient care over the currently approved outpatient observation level of care. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to Medicare rules. Therefore, this enrollee does not meet requirements for an inpatient stay for the approved total knee replacement.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 not been met.Therefore, we decided that the Plan does not have to pay for a knee replacement surgery at the inpatient level of care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluticasone/Salmeterol 250/50 Diskus.
You asked the Plan to pre-approve Fluticasone/Salmeterol. You say that this medication is medically
necessary. The Plan denied your request. The Plan says coverage for this drug is not available under the Part B
medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fluticasone/Salmeterol
250/50 Diskus.
Benefits for Fluticasone/Salmeterol may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided on January 21,
2020.
You asked the Plan to waive the coinsurance for genetic testing. You say that you disagree with the charges.
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the
correct amount.
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 genetic testing.
You received genetic testing on January 21, 2020. The allowed amount is $3,162.70 and 20% of that is
$632.54.
You have been asked to pay the total coinsurance amount of $632.54 for genetic testing. Genetic testing falls
within the outpatient diagnostic tests and therapeutic services and supplies 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 coinsurance for genetic testing provided on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvereplacement socket for shower leg prosthesis (L5700, L5620, L5629, L5637, L5668, L5673, L5910 and L5940).You asked the Plan to pre-approvereplacement socket for shower leg prosthesis. You say that the plan had originally approved an aquatic leg previously, but due to the large volume loss in the leg, he now wears 22-ply of socks for proper fit.The Plan denied your request. The Plan says that the request for new transtibial prosthetic socket does not meet Medicare criteria as reasonable and necessaryThe Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve replacement socket for shower leg prosthesis. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee is status post below-the-knee amputation. He is a functional level 3 ambulator. He utilizes an aquatic swim leg for exercise purposes. Authorization has been requested for a replacement socket. It is noted that the current aquatic prosthesis socket does not fit due to residual limb volume loss. The requested item is medically necessary for the enrollee. Medicare criteria have been met to support the medical necessity of the requested socket due to changes in the residual limb.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of replacement socket for shower leg prosthesis have been met.Therefore, we decided that the Plan has to pre-approvereplacement socket for shower leg prosthesis (L5700, L5620, L5629, L5637, L5668, L5673, L5910 and L5940).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says there are no notes in the medical records explaining why the additional visits are needed after already receiving these services for a 60 day time span.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the records do show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The documentation does not reveal evidence of complex wound care, new enteral feedings, IV medications or other professional skilled nursing need. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve3 additional physical therapy visits from an out-of-network provider.You asked the Plan to pre-approve3 additional physical therapy visits. You say that you don't want to go into a medical office. You say that you would like to continue the rest of your treatment with this provider.The Plan denied your request. The Plan says the additional visits from an out-of-network provider are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 3 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you had prior therapy and have been trained in a home exercise program. Our physician reviewer also found that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 additional physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve3 additional physical therapy visits from an out-of-network provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional 30 minutes of prolonged inpatient evaluation
& management (EM) services provided on January 14, 2020 billed with code 99357.
You asked the Plan to pay for the billed EM code. You say that the records support the services as billed. The
Plan denied your request. The Plan says it was determined that payment should be made for code 99356;
however, the records do not support payment for 99357 as well.
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 99357 is Prolonged service in the inpatient or observation
setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in
addition to code for prolonged service). CPT code 99356 (which was approved for payment) is defined as
Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service;
first hour (List separately in addition to code for inpatient Evaluation and Management service).
We find that CPT code 99357 is not supported in the medical record. Specifically, the progress note from
January 14, 2020 documents that 95 minutes were spent providing care. This amount of time was reported and
paid via codes 99233 and 99356, 35 minutes plus an additional hour of prolonged services. There is no
documentation of an additional 30 minutes beyond this to justify code 99357. Based on this information, we
decided that Medicare rules for coverage of the billed EM code have not been met. Therefore, we decided that
the Plan does not have to pay for the additional 30 minutes of prolonged inpatient evaluation & management
(EM) services provided on January 14, 2020 billed with code 99357.