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

We decided that the Plan does not have to pay for the CDP-SOT provided on July 13, 2020. 
 
You asked the Plan to pay for CDP-SOT (92548). You say that the medically necessary services were provided 
in good faith. The Plan denied your request. The Plan says this service is investigational and therefore not 
eligible for coverage. 
 
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 CDP-SOT (92548). Our reviewer says that 
the service was not considered medically reasonable and necessary in this case. Our physician reviewer found 
current evidence was reviewed on the CDP-SOT testing method and it is still considered investigation with 
insufficient validating studies to confirm its benefit in this clinical setting. Therefore, this request for such 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 CDP-SOT have not been met. Therefore, we decided that the Plan does not 
have to pay for the computerized dynamic posturography sensory organization test (CDP-SOT) provided on 
July 13, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveCT, thorax; without contrast material (CPT Code 71250).You asked the Plan to pre-approvethe CT scan. You say that the service is necessary.The Plan denied your request. The Plan says that the service is not necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan. Our physician reviewer found The Fleischner Society Guidelines recommends interval CT every 3-6 months for high risk patients where multiple lesions at least one of which is greater than 8 mm were found on previous imaging such as in this case. The patient is high risk due to prior recent history ofrenal cancer and is at high risk for lung cancer and had multiple lesions on prior CT in August 2020, one of which was 9 mm in diameter warranting a 3-6-month interval until the next CT scan. Since it has been three (3) months at the time of this review, it will be considered medically necessary to have another chest CT to evaluate the lesions for any growth.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 CTscan have been met.Therefore, we decided that the Plan has to pre-approveCT, thorax; without contrast material (CPT Code 71250).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says medical records were requested from your provider but were not 
received. The Plan states that the services billed by your provider are not covered by the Plan or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 20, 
2020, to July 25, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
denial. 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 $325 
copayment for days 1-6 for inpatient hospital care.  
 
You had an inpatient hospital stay from July 20, 2020, to July 25, 2020. Therefore, you are responsible to pay a 
$325 copayment for days 1-6 (July 20, 2020, to July 24, 2020). $325 (copayment) x 5 (inpatient days) = 
$1,625.  
 
You have been asked to pay the total copayment amount of $1,625 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay from July 20, 2020, to July 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen G4 portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve an Inogen G4 portable oxygen concentrator. You say that the requested item 
is necessary. The Plan denied your request. The Plan says duplicate equipment is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a portable oxygen concentrator. A portable oxygen concentrator serves the 
same purpose as an Inogen G4 portable oxygen concentrator. Therefore, we decided that the Plan does not have 
to pre-approve an Inogen G4 portable oxygen concentrator (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post stabilization care provided. 
 
You asked the Plan to pay for the post stabilization care. You say that you would like reconsideration because 
the services rendered were medically necessary. The Plan denied your request. The Plan says the enrollee's 
emergency medical condition stabilized by and subsequent care was post stabilization 
care. 
 
 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that the physician did not document in the records that the member was not stable for transfer on any date of 
service. Our physician reviewer found, the provided records document vitals were 
stable and the member was stable to transfer to an in-network hospital by ambulance. 
 
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 post stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for post stabilization care provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound care services to be provided by a specialist. 
 
You asked the Plan to pre-approve wound care services to be provided by a specialist. You say that the services 
are necessary. The Plan denied your request. The Plan says approval was not received from the PCP. Therefore, 
coverage criteria has not been met. 
 
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 
wound care services to be provided by a specialist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuation of SNF care from November 23, 2020, forward.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.We decided that the Plan does not have to pre-approvecontinuation of SNF care from November 23, 2020, forward.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the X-ray of ankle (73600) provided on 
June 15, 2020, to June 29, 2020. 
 
You asked the Plan to waive the copayment for the X-ray of ankle. You say that you should not have been 
charged a copayment. The Plan denied your request. The Plan says the copayment applied correctly in this 
case. 
 
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 specialist physician services.  
 
You have been asked to pay a $40 copayment for the X-ray of ankle. The X-ray of ankle falls within the 
specialist physician 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 X-ray of 
ankle (73600) provided on June 15, 2020, to June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IV tubing extension set or infection control supplies 
provided on June 15, 2020. 
 
You asked the Plan to pay for the supplies. You say that the equipment and supplies were necessary during and 
after the enrollee's procedure. The Plan denied your request. The Plan says these procedure codes are not valid 
for Medicare purposes. 
 
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 S1015 is IV tubing extension set, and  S9301 is infection 
control supplies. 
 
We find that CPT code S1015 and S9301 are not a valid code for Medicare purposes. S codes are unique 
temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by 
Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this 
information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for the IV tubing extension set or infection control supplies provided 
on June 15, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the head or brain (70470). 
 
You asked the Plan to pre-approve a CT scan of the head or brain. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the head or brain. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the history of prior 
Chondrosarcoma 4 years ago is of concern in this enrollee with constitutional symptoms (weight loss) and the 
history of pulmonary nodules with one having increased in size speaks to the possibility of hematogenous 
spread of tumor. Hence, the request to scan the brain to evaluate for possible metastasis is reasonable. 
 
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 CT scan of the head or brain have been met. Therefore, we decided that the 
Plan has to pre-approve a computed tomography (CT) scan of the head or brain (70470).  
 
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 CardioMEMS device (CPT Codes: C2624 and 33289). 
 
You asked the Plan to pre-approve the device. You say that the enrollee needs this device and procedure due to 
the enrollee's worsening heart failure. The Plan denied your request. The Plan says the notes do not show that 
the enrollee has been enrolled in an approved category B investigational device exemption (IDE) study. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this circumstance, therapy change based on data obtained from a CardioMEMS device 
has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical 
therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not 
met, since the device should still be considered experimental or investigational. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CardioMEMS device (CPT Codes: C2624 and 33289).
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 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 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 there are no services at the LTACH that are not already available and covered at the 
current facility. Therefore, this request for LTACH services will be considered not medically necessary at this 
time. Transfer to a lower level of care may be considered when treatment has completed. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pneumatic compression device (E0675)and sleeve (E0673) provided to the enrollee on May 15, 2020.You asked the Plan to pay forthese services. You say that these services were medically necessary.The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.Therefore, we decided that the Plan does not have to pay forthe pneumatic compression device (E0675) and sleeve (E0673) provided to the enrollee on May 15, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the 
enrollee. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the enrollee 
is only covered for 100 days each benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from February. 
The Plan has covered 100 days of SNF care.
 
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
 
 
that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
SNF services are medically necessary. The Plan denied your request. The Plan says the member does not need 
daily skilled services that can be provided only on an inpatient basis in an SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anterior or anterolateral approach technique arthrodesis 
procedures on the spine (vertebral column) 22551 and 2252 provided April 22, 2020. 
 
You asked the Plan to pay for the spinal arthrodesis. You say that please review the requested med notes for 
date of service 4/22/20. The Plan denied your request. The Plan says 63081 and 2251 (line 3) bundle as more 
extensive procedure. Line 4 (22552) is the add on procedure to line 3. CPT codes 22551 and 22552 are denied 
as medical records do not support modifier 59. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 spinal arthrodesis. Our physician 
reviewer found the documentation submitted was reviewed, and does not meet criteria. CPT 63081, CPT 22551 
and CPT 22552 are not separately reported unless done at another site. Documentation does not support distinct 
procedural services were performed. 
 
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 spinal arthrodesis have not been met. Therefore, we decided that the Plan 
does not have to pay for anterior or anterolateral approach technique arthrodesis procedures on the spine 
(vertebral column) 22551 and 2252 provided April 22, 2020.