Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837), provided on September 22, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the service should be covered. The Plan denied 
your request. The Plan says there was no documented contact with the attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy (90837), provided on 
September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on December 13, 2021, through 
December 23, 2021. 
 
You asked the Plan to pay for the office visits. You say that the service should be covered. The Plan denied 
your request. The Plan says you obtained this service from a provider who has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visits provided on December 13, 2021, through December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a short-latency somatosensory evoked potential (SSEP), a 
central motor evoked potential (MEP) study, and an electroencephalogram (EEG) rendered on October 11, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says experimental or investigational services are not covered. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that according to recent publications on the topic of intraoperative neuromonitoring (IONM) in anterior 
cervical spine procedures there is no difference in the risk of neurological injury with or without IONM use. Given that the current body of published evidence has failed to conclusively show that IONM leads to 
improvement in outcomes in single level anterior cervical fusion procedures--the services provided would not 
have been medically necessary and standard of 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a short-latency somatosensory evoked potential (SSEP), a central motor evoked potential 
(MEP) study, and an electroencephalogram (EEG) rendered on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on May 18, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed 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, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. 
 
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 physician services. Our reviewer says that the code billed 
is not supported in the records. Our reviewer found the documentation did not support that a comprehensive 
history was performed. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0402 and G0463 billed for date of service 
June 13, 2022. 
 
You asked the Plan to pay for procedure codes G0402 and G0463. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 G0402 and G0463 are not supported in the case record. Specifically, a review of the 
file shows that the claim was not billed with condition code G0. Billing multiple medical visits in the same day 
requires this condition code. Based on this information, we decided that Medicare rules for coverage of 
procedure codes G0402 and G0463 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes G0402 and G0463 billed for date of service June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ablation of malignant prostate tissue (high-intensity 
focused ultrasound - HIFU). 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show that this requested treatment of prostate cancer will be as 
efficacious as the standard of care. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, the record indicates that the enrollee has locally recurrent prostate cancer 
previously treated with the requested service. There is insufficient literature to support the safety and efficacy 
of the requested service for the enrollee's clinical condition. The elements of the coverage criteria are not 
satisfied. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ablation of malignant prostate tissue (high-intensity focused ultrasound - HIFU).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 9, 2022 to May 
18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 9, 2022 to May 18, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued psychiatric hospital care. 
 
You asked the Plan to pre-approve continued psychiatric hospital care. You say that the enrollee was admitted 
involuntarily due to psychosis and suicidal ideations with a plan. She states that she planned to cut her wrists 
and had walked into traffic earlier in an attempt to be hit by a car. The Plan denied your request. The Plan says 
the request does not meet Medicare guidelines because records show the enrollee is not having plan or intent to 
harm herself. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continued psychiatric hospital care. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee was 
compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care beyond the dates in question as she did not have dangerousness to self or others and was compliant with 
her treatment. The health plans denial of continued inpatient psychiatric services is appropriate. This enrollee 
did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger 
to herself or others and does not have auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. She was treated 
under an individualized treatment plan found in the record. It did appear that the records were supervised and 
evaluated by a physician. Based upon review the records provided for the admission of this enrollee does not 
meet the criteria for March 7, 2023, forward as this enrollee was not shown to be a danger to herself or others, 
delusions, auditory or visual hallucinations noted. She was cooperative/compliant with treatment while not 
showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued psychiatric hospital care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued psychiatric hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan 
provided on November 4, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that your physician suggested that you get an 
MRI and that it would be covered. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $250 
copayment for outpatient Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $250 copayment for an MRI. This item/service falls within the outpatient 
Medicare-covered diagnostic radiology services that are not ultrasounds benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan provided on November 4, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for code 71275-26 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for code 71275-26. You say that this claim is not a duplicate, but an updated claim 
that was paid and taken back. The Plan denied your request. The Plan says that this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, we find two separate reasons why the 
Plan has failed to meet its burden of proving that this claim was a duplicate.  First, in its case narrative to us, 
the Plan contends that it paid for this code on September 22, 2022.  However, the Plan has failed to provide any 
evidence of that payment (such as a check, remittance advice, etc.) showing that indeed this disputed code was 
paid.  Second, you contended that the payment for this code was taken back.  The Plan has failed to address this 
argument at all in the case file it provided to us.  The burden is on the Plan to show that its denial is correct.  
Because the Plan's sole argument for denial is predicated on this claim being a duplicate, and the Plan has 
failed to provide the needed evidence proving that a duplicate claim was paid, we find that the Plan has not met 
this burden. Based on this information, we decided that Medicare rules for coverage of code 71275-26 have 
been met. Therefore, we decided that the Plan has to pay for code 71275-26 billed for date of service July 6, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an influenza virus vaccine provided on October 12, 2022, by 
an out-of-network provider. 
 
You asked the Plan to pay for the influenza virus vaccine. The Plan denied your request. The Plan says the Plan 
must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care 
and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 an influenza virus vaccine provided on October 12, 2022, by an 
out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the depression screening (G0444), provided on November 
29, 2021. 
 
You asked the Plan to pay for the depression screening. You say that the service should be covered. The Plan 
denied your request. The Plan says you have exhausted the Plan benefit for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that screening for depression is non-covered when 
performed more than one time in a 12-month period. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the depression screening have not been met. Specifically, submitted documentation indicated you 
received this service on June 24, 2021. This means the benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the depression screening (G0444), provided on November 29, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services (G0299). 
 
You asked the Plan to pre-approve home health services. You say that you disagree with the denial. The 
enrollee needs physical therapy, and she cannot stand on her own. The Plan denied your request. The Plan says 
that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care 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 home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found the requested 
home health physical therapy is generally accepted as reasonable and necessary for the enrollee's impaired 
mobility and ability to perform transfers. The documentation provided includes a home health plan of care. The 
most recent home health occupational therapy notes dated February 28, 2023, indicated an occupational 
therapy discharge was completed on February 28, 2023. The enrollee had made maximum potential with 
skilled occupational therapy and will be transitioned to physical therapy. The enrollee is noted to require home 
health physical therapy. Therefore, the home health physical therapy can be considered 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 home health services have been met. Therefore, we decided that the Plan has to 
pre-approve home health services (G0299).  
 
 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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has CRF due from COPD and 
has been 02 at normal level. The requested device is medically needed. The Plan denied your request. The Plan 
says the requested device does not meet the requirements for approval. 
 
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 the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As 
stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a third level of procedure code 64495 rendered on October 
28, 2022. 
 
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 provider did not send in evidence of a unique circumstance to indicate a three or four level 
injection. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that multiple interventions would not be appropriate for one date of service. The enrollee had both 
medial branch blocks and transforaminal steroid injections on the same day. The performance of both sets of 
blocks precludes knowing which blocks treated the pain generator.  
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 pay for a third level of procedure code 64495 rendered on October 28, 2022.