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

 
We decided that the Plan does not have to pay for laboratory testing provided from September 4, 2019, to 
September 11, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation submitted does not include a valid physician order, lab requisition, or medical records for the 
tests billed and does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided from September 4, 2019, to September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 18, 2020, by an 
out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services received required 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 February 18, 
2020, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a whole body bone scan for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this study is not supported in the absence of signs or symptoms of breast cancer 
recurrence. 
 
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 scan. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is asymptomatic. Routine surveillance is not indicated. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a whole body bone scan for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 2, 
2020, to March 4, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the Plan should pay for the inpatient 
services. The Plan denied your request. The Plan says the enrollee did not meet inpatient criteria. 
 
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 care provided to the enrollee was observation level. There were no advance 
interventions or complex medical conditions. The enrollee had stable vital signs and no complaints at the time 
of admission. Inpatient services were not supported by the documentation. The denial is upheld. 
 
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 the acute inpatient hospital care provided from March 2, 2020, to March 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (51798) provided July 9, 
2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the correct cost-share was applied. 
 
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 $10 
copayment for Radiologic Diagnostic Services.  
 
You have been asked to pay a $9.86 copayment for the ultrasound. The ultrasound falls within the Radiologic 
Diagnostic Services benefit category. In this case, the Medicare allowable amount of $9.86 is less than the $10 
copayment noted in the plan contract. 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 ultrasound 
(51798) provided July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT Code 64625). 
 
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee presents with complaints of chronic low back pain and bilateral lower extremity 
pain. The enrollee is status post revision L1-S1 bilateral laminectomy on March 16, 2020, for neurogenic 
claudication. The enrollee is status post two right sacroiliac joint injections with 80-90% pain reduction for 4 
weeks. Clinical exam findings include positive right sacroiliac joint tenderness and provocative testing. There 
is no imaging evidence of right sacroiliac joint pathology. Detailed evidence of a recent, reasonable and/or 
comprehensive non-operative treatment protocol trial directed to the right sacroiliac joint, such as physical 
therapy, and failure has not been submitted. Current evidence based medical literature indicates that there is 
limited data supporting the safety and efficacy of this treatment. There is a lack of large volume, long-term 
peer-reviewed outcome studies to support the use of these procedures for this enrollee as discussed above. 
Therefore, this request for sacroiliac joint radiofrequency ablation is 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, 
fluoroscopy or computed tomography) (CPT Code 64625).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on April 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for a home health visit. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 a home health visit provided on April 27, 2020 by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for phalangeal shaft fracture treatment (26725) provided on 
October 31, 2019. 
 
You asked the Plan to pay for phalangeal shaft fracture treatment. You say that this is supported in the 
documentation. The Plan denied your request. The Plan says this was not billed correctly. 
 
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 26725 is closed treatment of phalangeal shaft fracture, 
proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each. 
 
We find that CPT code 26725 is not supported in the medical record. Specifically, the submitted medical 
records indicate that the enrollee did not have a fracture and was instead treated for dislocation. Based on this 
information, we decided that Medicare rules for coverage of phalangeal shaft fracture treatment have not been 
met. Therefore, we decided that the Plan does not have to pay for phalangeal shaft fracture treatment (26725) 
provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter for the enrollee. 
 
You asked the Plan to pre-approve a power scooter. You say that the member is unable to stand for extended 
periods of time and this prevents her from getting around her place where she lives. The Plan denied your 
request. The Plan says that the record did not show that the member's condition prevented her from 
accomplishing her MRADLs entirely. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that the enrollee has a mobility deficit that impairs the enrollee's participation in 
MRADLs or that the enrollee's condition cannot be improved by a walker, cane or manual wheelchair. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (CPT 97110 and CPT 97530) 
provided to the enrollee from November 8, 2019, to December 23, 2019. 
 
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 submitted documentation does not support the total time required for the billed services. 
 
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 97110: 
 
therapeutic procedure, on one or more areas, each lasting 15 minutes 
 
CPT 97530: 
 
therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve 
functional performance), each 15 minutes 
 
We asked our coding 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 
services at issue in this case were not supported by the medical records. Our coding reviewer found the time 
spent on therapy was not documented; therefore, the codes cannot be verified. 
 
 
 
 
 
 
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 physical therapy services (CPT 97110 and CPT 97530) provided to the enrollee from 
November 8, 2019, to December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy of a premolar tooth (D3320) and 
endodontic therapy of a molar tooth (D3330). 
 
You asked the Plan to pre-approve the endodontic therapies. The Plan denied your request. The Plan says these 
services are 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 pre-approve 
endodontic therapy of a premolar tooth (D3320) and endodontic therapy of a molar tooth (D3330).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 14, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 emergency 
situation, 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 subsequent nursing facility care provided on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator, garment type provided 
from January 5, 2020, to February 5, 2020. 
 
You asked the Plan to pay for the automatic external defibrillator (AED). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the enrollee received the AED in the facility during 
inpatient hospitalization. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a hospital to be a home.  
 
Records show that the automatic external defibrillator (AED) was supplied while the enrollee was in a hospital. 
Payment for this service would have been included under the global facility claim. Therefore, we decided that 
the Plan does not have to pay for the automatic external defibrillator, garment type provided from January 5, 
2020, to February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (CPT Code 
E0745) provided on April 26, 2020. 
 
You asked the Plan to pay for the DME. You say that the service is medically necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. You are known to the Health Plan as 
employing a Teladoc consult to obtain the medical necessity information for the durable medical equipment. 
The Plan states this provider conducts unsolicited outreach telephone calls to enrollees and enrollees are not 
initiating a request to be contacted by this provider. The Plan states a physical examination by the ordering 
physician is not completed and clinical information is obtained by the provider via telephone interview.  
 
The Plan states it is unknown if the telephonic interview is conducted by a physician or employee of this 
provider. The Plan states that some enrollees have indicated they never spoken to the ordering physician 
documented in the records and there are no documented attempts to contact this enrollee's local physician. 
Therefore, we decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit 
(CPT Code E0745) provided on April 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services coded 
99239 provided on March 2, 2020. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge 
summary does not include a hospital discharge day management of more than 30 minutes was performed. A 
documented duration of 31 minutes or more is required to support this code. Based on this information, we 
decided that Medicare rules for coverage of the hospital discharge day management services have not been met. 
Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services 
coded 99239 provided on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, premolar tooth on tooth #20 
(D3320) and endodontic therapy, molar tooth on tooth #19 (D3330). 
 
You asked the Plan to pre-approve endodontic therapy, premolar tooth on tooth #20 and endodontic therapy, 
molar tooth on tooth #19. You say that the services are necessary. The Plan denied your request. The Plan says 
the services are not a covered benefit. 
 
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 pre-approve 
endodontic therapy, premolar tooth on tooth #20 (D3320) and endodontic therapy, molar tooth on tooth #19 
(D3330).
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 enrollee needs to successfully regain 
maximum independence. The Plan denied your request. The Plan says the enrollee's medical needs are being 
met in the current acute setting. 
 
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 physician 
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a 
cardiac arrest. The enrollee was intubated/ventilated upon presentation and subsequently received a 
tracheotomy. He remains on a ventilator and is tolerating only minimal weaning. His neurologic status appears 
to be poor. There is no evidence that the enrollee requires services at the LTACH that are not currently 
available at the ACH.  As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on June 8, 2020. 
 
You asked the Plan to pay for the testing services. You say that medical records support the medical necessity. 
The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment 
panels, except the basic lipid panel. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation.  
 
The documentation shows that pharmacogenetic testing was provided. We looked at the file and Medicare 
rules. The provided pharmacogenetic testing was reportedly ordered to make decisions about the enrollee's 
medications. Medications should be provided based on the presence of a diagnosis and should be adjusted 
based on a response to the medication. Furthermore, genetic markers may or may not correlate with actual 
clinical findings. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab testing provided on June 8, 2020.