Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 9 HHA visits. We decided that the Plan does not have to pre-
approve 7 HHA visits.  
 
You asked the Plan to pre-approve 16 HHA visits. You say that you would like reconsideration because these 
services are medically necessary and have always been covered in the past. The Plan says that this is 
considered custodial care. 
 
We decided that the Plan has to pre-approve 9 HHA visits.  
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
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 9 HHA visits. Our reviewer says that 
documentation shows that the enrollee requires daily skilled nursing care and intermittent HHA services. The 
care plan is for the enrollee to receive HHA services thrice weekly. Our physician reviewer found thrice 
weekly HHA visits are medically necessary and 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 9 HHA visits have been met. Therefore, we decided that the Plan has to pre-
approve 9 HHA visits.  
 
We also decided that the Plan does not have to pre-approve 7 HHA visits. 
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
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 7 HHA visits. Our reviewer says that 
thrice weekly HHA visits are medically necessary and reasonable. The additional 7 HHA visits are 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 7 HHA visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 7 HHA visits. 
 
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: 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 you are alone most days and need to be in a position 
to be able to carry out daily life skills in a safe manner. You also say that an IRF will best prepare you for this. 
The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 there are no rehabilitation nursing needs identified or documented in the record. Our 
reviewer found that you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 
5 days per week with multidisciplinary approach to daily therapy in an IRF. Our physician reviewer also found 
that while you may benefit from physical therapy and occupational therapy, your rehabilitation can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility or in-home with services. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BRCA1, BRCA2 (breast cancer 1 and 2) (81162) provided 
June 8, 2021. 
 You asked the Plan to pay for genetic testing. You say that please review the claim for medical necessity. 
Based on the above information, the physician's decision to order the test, and the enrollee meeting the Plan's 
medical policy, you are requesting reimbursement for this claim. The Plan denied your request. The Plan says 
the enrollee does not meet the evidence-based criteria set by the LCD for this type of testing. 
 
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 genetic testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the member does not have specific gene mutations in the family 
history or other related cancers associated with BRCA to warrant individual testing. For Prostate cancer at any 
age, being Ashkenazi Jewish, member needs a Gleason score of 7 or greater. Member has a score of 6. Other 
criteria were also not met. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for BRCA1, BRCA2 (breast cancer 1 and 2) (81162) provided June 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy evaluation (97167) provided on 
July 23, 2020. 
 You asked the Plan to pay for therapy services. You say that these services were medically necessary and were 
billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 97167 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by an 
Occupational Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of therapy services have not been met. Therefore, we 
decided that the Plan does not have to pay for the occupational therapy evaluation (97167) provided on July 23, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided by a network 
physician on October 28, 2021. 
 
You asked the Plan to waive the deductible for the office visit. You say that this was an annual visit to renew 
medicine and discuss laboratory results. The Plan denied your request. The Plan says you have been asked to 
pay the correct cost-sharing 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 $198 deductible which applies to each in-network primary care 
physician's office visit.  
 
The office visit you asked the Plan to waive the deductible for falls within the Physician/Practitioner services, 
including doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $198 deductible which applies to each in-network primary care physician's office 
visit. This cost sharing is a contractual obligation that had not been met at the time the office visit was received 
on October 28, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the office 
visit provided by a network physician on October 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on December 16, 
2020. 
 
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 documentation does not support this level of care. 
 
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 72114 is "Radiologic examination, spine, lumbosacral; 
complete, including bending views, minimum of 6 views." 
 
We asked our coder 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 reviewer found the record indicates that the enrollee 
underwent an X-ray examination on December 16, 2020. The record as provided is insufficient to demonstrate 
that the service was provided consistent with the CPT code billed. 
 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 imaging services provided to the enrollee on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601, E0562). 
 
You asked the Plan to pre-approve a CPAP device. You say that the enrollee needs to continue using this 
device. The Plan denied your request. The Plan says supporting documentation has not been received. 
 
The Plan must follow Medicare rules. Medicare rules say that if a positive airway pressure (PAP) device is 
replaced during the 5-year reasonable useful lifetime (RUL) because of loss, theft, or irreparable damage due to 
a specific incident, there is no requirement for a new clinical evaluation, sleep test, or trial period. If a PAP 
device is replaced following the 5 year RUL, there must be an in-person evaluation by their treating 
practitioner that documents that the beneficiary continues to use and benefit from the PAP device. 
 
We looked at the file and Medicare rules. The record indicates that the enrollee currently has a CPAP device. 
The submitted records do not document that this device has been lost, stolen, or damaged. Records have not 
been submitted for an in-person evaluation that shows the enrollee uses and benefits from the CPAP device. 
Without this information, a replacement is not supported. Based on this information, we decided that Medicare rules for coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous positive airway pressure (CPAP) device (E0601, E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on April 23, 2021, 
and billed under code 99053. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says while a portion of this claim was paid, code 99053 has a status indicator of 'B' on the 
Medicare Physician Relative Value File and is always bundled into payment for other services not specified. 
No separate payment is made per Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, code 99053 cannot be paid separately as 
billed. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee 
on April 23, 2021 and billed under code 99053.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on November 9, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for skilled nursing facility services provided on November 9, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on January 22, 2021, and 
January 29, 2021. 
 
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 the provider is a non-participating provider. There is no referring 
provider involved in these services. Our plan did not authorize any services for this provider. The services were 
rendered in a telehealth setting. The services denied as not a covered benefit as the provider did not bill the 
claim as directed by Medicare.  
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that physician services can require prior authorization and if you use out of network providers your cost share 
may be higher. The claim submitted by the provider does not show these services were urgent or emergent, nor 
were they billed appropriately.  
 Because the provider is out of network, the Plan cannot compel the provider to submit a corrected claim. 
Therefore, we decided that the Plan does not have to pay for telehealth services provided on January 22, 2021, 
and January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you would like reconsideration because the 
requested ventilator is medically necessary. The Plan denied your request. The Plan says the home ventilator is 
not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. You improved on bilevel positive airway pressure (BiPAP), 
and an arterial blood gas showed a normal partial pressure of carbon dioxide in arterial blood of 39. Our 
physician reviewer found you may benefit from continued BiPAP during sleep.  Medicare does not cover a 
home ventilator for the diagnosis of obesity hypoventilation syndrome, or when used as BiPAP.  BiPAP has not been tried at home. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve bilateral magnetic resonance imaging (MRI) of the shoulders. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there has not been six weeks of completed provider-directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that in terms of the right 
shoulder, the enrollee has had prior physical therapy with only modest success. He has had advanced 
degenerative joint disease right shoulder noted on x-ray. MRI is the next procedure of choice. In terms of the 
left shoulder, the NEER and Hawkins tests are positive. There is left arm weakness. The x-ray showed Hill 
Sachs deformity. These are red flags for immediate MRI without a six week trial of physical therapy. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
bilateral magnetic resonance imaging (MRI) of the shoulders.  
 
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 pay for the surgical services provided on December 14, 2021, billed 
with code 34201, provided on the same date as code 35876. 
 
You asked the Plan to pay for the surgical services as billed. You say that this is correctly billed and should be 
paid. The Plan denied your request. The Plan says the records support that 34201 was performed, but this 
service is considered to be reimbursed through code 35876. 
 
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 34201 is embolectomy or thrombectomy, with or without 
catheter; femoropopliteal, aortoiliac artery, by leg incision. The description of the paid code 35876 is 
thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with revision of arterial or 
venous graft. 
 
 We asked our coder 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 surgical services as billed. Our reviewer says that the 
documentation does not support payment for both 34201 and 35876 on the same date of service. Payment for 
34201 is included in 35876. Our reviewer found per Chapter 5 of the NCCI manual, "When an open or 
percutaneous vascular procedure (e.g., thromboendarterectomy) is performed, the repair and closure are 
included components of the vascular procedure. CPT codes 35201-35286 (Repair of blood vessel including 
extensive repair) are not separately reportable in addition to the primary vascular procedure unless the CPT 
code descriptor states that repair or closure is separately reportable." 
 
Repair and closure of a blood vessel used for vascular access during the performance of a procedure is an 
included component of that procedure. Repair of the blood vessel (e.g., CPT codes 35201-35286) shall not be 
reported separately.  Although there is no NCCI edit when reporting CPT 34201 and CPT 35876, services were 
performed on the same side, and therefore would not be reported separately. 
 
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 surgical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgical services provided on December 14, 2021, billed with code 34201, 
provided on the same date as code 35876.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided the Plan does not have to pay for services billed for June 23, 2021, under code 12002. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says while code 99285 will be paid, a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 12002 and 23650. This PTP edit has a modifier indicator of 1, which 
indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed 
with this PTP code edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to 
the omission of the required modifier. Therefore, we decided that the Plan does not have to pay for services 
billed to the enrollee for June 23, 2021, under code 12002.