Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for endoscopy services (43264 and 43261) provided on October 31, 2019. 
 
You asked the Plan to pay for the endoscopy services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that payment for the procedure with the 
highest allowance was made under CPT code 43274. 
 
The Plan must follow Medicare rules. Medicare rules say that if Field 21 contains an indicator of ?3,? pay the 
full value of the highest valued endoscopy, plus the difference between the next highest and the base 
endoscopy. 
 
We find that CPT code 43264 and 43261 is supported in the record. Specifically, there is no evidence that the 
difference between the next highest and base endoscopy has been paid. Based on this information, we decided 
that Medicare rules for coverage of the endoscopy services have been met. Therefore, we decided that the Plan 
has to pay for endoscopy services (43264 and 43261) provided on October 31, 2019.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 21, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 drug testing services provided on June 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328). 
 
You asked the Plan to pay for home infusion therapy. You say that previous uses of this case have been paid. 
The Plan denied your request. The Plan says this code is 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. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status 
indicator of "I". Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autograft for spine surgery only (20936) provided 
October 9, 2019. 
 
You asked the Plan to pay for the autograft for spine surgery only. You say that you do not believe the 
reduction applied by the insurance is justified. Your appeal is only to seek what you are legally entitled to. The 
Plan denied your request. The Plan says no separate payment can be made for this bundled service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the 
20936 has a bundled relationship with the primary procedure and cannot be paid as billed. This code cannot be 
paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for the autograft for spine surgery only (20936) 
provided October 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is 
mostly minimal assist for functional transfers and activities of daily living (ADL?s) and a less intensive, longer 
duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An 
IRF intensity is not warranted. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan on a limited area (78814). 
 
You asked the Plan to pre-approve a PET CT scan of a limited area. 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 PET 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 PET CT scan of a limited area. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a valid 
indication for PET/CT as a determining factor in deciding a chemotherapeutic agent. Also, paradoxically the 
plan's statement confirms PET/CT is the most useful imaging study for this enrollee's care. There is a statement 
that if PET/CT were to be requested it would be approved. This implies that there is a communication problem 
between the plan and the oncologist. In any case, the requested PET/CT scan is indicated and should be 
approved as the best scan 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 a PET CT scan of a limited area have been met. Therefore, we decided that the 
Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) scan on a limited area (78814).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint neurolysis. 
 
You asked the Plan to pre-approve the services. You say that waiting thirty days can cause long term issues. 
The Plan denied your request. The Plan says the requested procedure is supported when two facet joint 
injections/medial branch blocks provided 80% or more pain relief for the duration of the agent used. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of any medial branch blocks for this new complaint. 
 
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 pre-approve facet joint neurolysis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, O2 care, and daily therapy can be provided at a SNF. In this case, the enrollee is 
mostly supervised assist for functional transfers and activities of daily living (ADL's) and a less intensive, 
longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted 
period. An IRF intensity is not warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations.
You asked the Plan to pre-approve radiofrequency ablations. You say that a previous procedure provided the enrollee with at least 50% pain relief for 11 months, so it is medically necessary to repeat the procedure. The Plan denied your request. The Plan says the denial of payment for these services is correct, because there is a lack of medical necessity for the 6-joint procedure requested.
The Plan follows Medicare rules. Medicare rules state that facet joint injection, medical branch blocks, and radiofrequency ablations may be covered under certain clinical criteria. The above listed limitations and exclusions apply to these 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 radiofrequency ablations. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found the number of radiofrequency ablations requested for this treatment session exceeds the Medicare limit, which states that no more than 2 thermal radiofrequency sessions will be reimbursed in any calendar year, involving no more than 4 joints per session (for example, 2 bilateral levels or 4 unilateral levels). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablations have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablations.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve upper eyelid blepharoplasty (15822). 
 
You asked the Plan to pre-approve upper eyelid blepharoplasty. You say that the enrollee meets medical 
necessity criteria for this procedure. The Plan denied your request. The Plan says that the records do not show 
the enrollee's vision is obstructed according to Medicare rules. 
 
The Plan follows Medicare rules. Medicare rules say that upper eyelid blepharoplasty is covered when 
medically necessary per the above guidelines. 
 
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 upper eyelid blepharoplasty. Our 
reviewer says that upper eyelid blepharoplasty is medically necessary in this case based on the functional 
complaints, visual field results and physical exam. Our physician reviewer found in this situation, it is clear that 
the patient has dermatochalasis as evidenced by photographs with eyelids touching the lash margin. The 
physical examination demonstrates photographs that does not meet criteria for coverage, however visual field 
tests are consistent with a functional deficit. Medicare LCD criteria allow for exception to the MRD criteria 
when there is compelling evidence of functional disability based on history and visual field information.  The 
visual fields, history and photographs are compelling evidence of functional disability in spite of the MRD 
measurements. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upper eyelid blepharoplasty have been met. Therefore, we decided that the Plan 
has to pre-approve upper eyelid blepharoplasty (15822).  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia injections. 
 
You asked the Plan to pre-approve Prolia injections (J0897). You say that you want the enrollee to be treated 
with this drug. The Plan denied your request. The Plan says there is no noted trial of bisphosphonates. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Prolia injections (J0897). Our reviewer 
says that the drug is not medically necessary. Our physician reviewer found it is unclear why an oral or iv 
bisphosphonate cannot be used as this is usually first line therapy for osteoporosis. Given the provided data, 
Prolia is 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 Prolia injections (J0897) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Prolia injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on March 6, 2020. 
 
You asked the Plan to waive the deductible for an office visit. You say that you disagree with the charges 
because the provider is in-network. 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. Your 
contract with the Plan says that there is a $400 deductible for physician/practitioner services, including doctor's 
office visits.  
 
You received an office visit from an out-of-network provider on March 6, 2020. The record shows that you had 
only paid $282.30 toward the $400 deductible. Therefore, you are responsible to pay the allowed amount of 
$117.70.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $400 deductible for physician/practitioner services, including doctor's 
office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was 
received on March 6, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an 
office visit provided on March 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is 
mostly moderate/minimal assist for functional transfers and activities of daily living (ADL's) and a less 
intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and 
predicted period. An IRF intensity is not warranted. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's appropriate therapy needs are not precluded in an 
alternate level of care such as skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for treatment of 
infection of knee prosthetic joint. Other medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient require does not treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the record supports a 
need for physical and occupational therapy, there is no documented need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the provider must 
billed Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 9, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided 
on January 16, 2020.