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

 
We decided that the Plan does not have to pre-approve ten (10) additional PT visits. 
 
You asked the Plan to pre-approve the ten (10) additional PT visits. The Plan denied your request. The Plan 
says additional physical therapy is 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 the ten (10) additional PT visits. Our 
reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is 
not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for 
this condition and it does not appear that you require the ongoing unique skills of a professional therapist to 
safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or under the supervision of a therapist. You have had instruction in a home exercise program with a 
caregiver. 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 
Medicare rules for coverage of the ten (10) additional PT visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 13, 2020 under 
with codes 81406, 81310, 81405, and 81404. 
 
You asked the Plan to pay these testing services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. The Plans denial states based on a Medicare Local 
Coverage determination; the enrollee did not meet the criteria required for these services. However, the 
regulation the Plan quoted was retired in November of 2018. In this case, the medical records provided do not 
support the codes billed. The records do not show that this testing was medically necessary to determine further 
treatment or diagnosis. That information was already present in the medical record without this testing. This 
testing is not covered as a screening. Medical necessity for this testing has not been established.  Therefore, we 
decided that the Plan does not have to pay for lab services provided to the enrollee on June 13, 2020 with codes 
81406, 81310, 81405, and 81404.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes (CPT Code 99291) and critical care, evaluation and 
management of the critically ill or critically injured patient; each additional 30 minutes (99292) provided on 
April 30, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 99291 and 99292 is not supported in the medical record. Current Procedural 
Terminology (CPT) code 99291 25 GC remains not supported. The documentation submitted did not support a 
critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not 
include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management 
code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional 
information. Current Procedural Terminology (CPT) code 99292 25 GC remains not supported. The required 
primary service code (CPT code 99291) is denied in the claim processing system (Reason Code 191); therefore, 
this service cannot be reimbursed separately. The parent code (99291) is not in the scope of the administration 
review department and was not considered for a determination during this review.  In addition, the submitted 
medical records do not include sufficient information to support additional critical care time. Documentation 
does not include the time spent providing this service; therefore, the service and modifiers cannot be verified. 
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 critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) and critical care, evaluation and 
management of the critically ill or critically injured patient; each additional 30 minutes (99292) provided on 
April 30, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you 
received from July 27, 2020, to July 28, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that this service should be covered 
because you needed help through the ER and they did help you. The Plan denied your request. The Plan says 
these services were covered, but the appropriate copayment 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 $90 
copayment for emergency services.  
 
You have been asked to pay a $90 copayment for the ER services. 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 emergency room (ER) services you received from July 27, 2020, to July 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on March 26, 2020. 
 
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 procedure code 99291 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care spent on the enrollee. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the critical care services rendered on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on August 
14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you were called at the request of 
the admitting physician. Please review and process payment for the medically necessary services rendered. The 
Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 subsequent nursing facility care (99309) provided 
on August 14, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the soft tissue of the neck. 
 
You asked the Plan to pre-approve a CT scan of the soft tissue of the neck. You say that the requested CT scan 
of the soft tissue of the neck is medically necessary. The Plan denied your request. The Plan says the requested 
CT scan of the soft tissue of the neck is not medically 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 a CT scan of the soft tissue of the neck. 
Our reviewer says that the requested CT scan of the soft tissue of the neck is not medically necessary. Our 
physician reviewer found based on the medical records provided, a CT scan is not medically reasonable or 
necessary. Based on the letter written, the enrollee had a normal flexible laryngoscopy exam. There is no 
indication that there was an abnormality found on the neck exam. Based on the enrollee's symptoms and her 
diagnosis, she does not warrant a CT scan at this time. In general, a CT scan is indicated if there is an 
abnormality seen on flexible laryngoscopy, on the neck exam, or if the patient has other concerning symptoms 
for a possible malignancy such as unexplained pain, sudden weight loss, inability to swallow secretions, sudden 
voice changes, or a neck mass. More medical records supporting the need for imaging would need to be 
submitted in order to meet criteria for a CT scan. 
 
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 soft tissue of the neck have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CT scan of the soft tissue of the neck.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies (A4222) provided from November 21, 
2019 through November 30, 2019. 
 
You asked the Plan to pay for the infusion supplies. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the records provided do not support the 
services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain valid proof of delivery for the supplies provided in this case. Specifically, the 
Delivery Ticket did not specify the date delivered or contain evidence of delivery. The Delivery Ticket also did 
not clearly link to the supplier's delivery documents. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the infusion supplies (A4222) provided from November 21, 2019 through November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on July 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable electrocardiographic event monitor (33285). 

You asked the Plan to pre-approve an implantable electrocardiographic event monitor (33285). You say that 
the requested implantable electrocardiographic event monitor (33285) is medically necessary. The Plan denied 
your request. The Plan says the requested implantable electrocardiographic event monitor (33285) 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 an implantable electrocardiographic 
event monitor (33285). Our reviewer says that the requested implantable electrocardiographic event monitor 
(33285) is not medically necessary. Our physician reviewer found based on the records the enrollee has 
palpitations that may represent recurrent atrial fibrillation.  In this circumstance, there is no documented 
unexplained syncope or cryptogenic stroke and standard initial monitoring would include prolonged Holter 
monitoring or external cardiac event monitoring.  The records do not support the medical necessity for routine 
monitoring with an implantable loop recorder at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable electrocardiographic event monitor (33285) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an implantable electrocardiographic event 
monitor (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D assay rendered on October 7, 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 the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a Vitamin D assay, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the Vitamin D assay rendered on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (99601 and 99602) provided on 
July 20, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT codes 99601 and 99602 have a status 
indicator of I which 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 codes 99601 and 99602 are not supported in the record. Specifically, per the Physician Fee 
Schedule, CPT codes 99601 and 99602 have a status indicator of I. This means that CPT codes 99601 and 
99602 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to 
pay for the home infusion therapy (99601 and 99602) provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (G0283) and the massage therapy 
(97124) provided on October 4, 2019 and November 1, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
the member's contractual policy. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulation (G0283) and the massage therapy (97124) 
provided on October 4, 2019 and November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on October 28, 2019. 
 
You asked the Plan to pay for annual wellness visit. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because you received an annual 
wellness visit on July 1, 2019 which was less than 12 months prior to this visit. 
 
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is only covered once 
every 12 months.  
 
We looked at the file and Medicare rules. You received a covered annual wellness visit on July 1, 2019; 
therefore, less than 12 months had passed before this annual wellness visit was provided. Based on this 
information, we decided that Medicare rules for coverage of annual wellness visit have not been met. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on October 28, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the service rendered from April 21, 2020 to April 30, 2020. 
 
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 are not covered. 
 
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. The provider submitted 
claims for procedure codes G0283 (electrical stimulation) and 99070 (supplies and materials). Therefore, we 
decided that the Plan does not have to pay for the service rendered from April 21, 2020 to April 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses (L1851, L2397) provided March 9, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied 
your request. The Plan says rules for a telehealth consult were not met, therefore the prescribed DME is non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
The record shows no prior relationship between the ordering physician and the enrollee. This means that the 
telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person 
encounter. Consequently, the items ordered following the non-covered visit are likewise non-covered. 
Therefore, we decided that the Plan does not have to pay for orthoses (L1851, L2397) provided March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer. 
 
You asked the Plan to pre-approve the device. You say that you would like reconsideration because this service 
is medically necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 this device is experimental and more research is needed to show its safety and efficacy. 
 
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 the Vertiflex Interspinous Spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urology services (52000, 51798) provided. 
 
You asked the Plan to pay for the urology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent and there were network providers 
available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 the urology services (52000, 51798) provided.