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

 
We decided that the Plan does not have to pay for the physical therapy services rendered on January 25, 2021. 
 
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 97164 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 97164 is re-evaluation of physical therapy established 
plan of care, requiring these components: An examination including a review of history and use of standardized 
tests and measures is required; and Revised plan of care using a standardized patient assessment instrument 
and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the 
patient and/or family.  
 
We find that CPT code 97164 is not supported in the medical record. Specifically, the file shows that the 
services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulator. 
 
You asked the Plan to pre-approve peripheral nerve stimulator. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found however, detailed documentation is not evident regarding trial and failure 
of recent, reasonable, and comprehensive less invasive conservative care measures directed at the cluneal 
nerve. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. Therefore, the requested peripheral nerve 
stimulator, in this case, is not medically reasonable or 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 peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve peripheral nerve stimulator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Orthovisc. 
 
You asked the Plan to pre-approve a tier exception for Orthovisc. You say that the exception is needed. The 
Plan denied your request. The Plan says the drug does not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a tier exception for Orthovisc.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) hospital outpatient clinic 
visit (G0463) and radiologic examination, chest (71046) provided on November 9, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee called your office on 11/09/2021 with 
complaints of cough and shortness of breath. She was advised to be evaluated urgently given her symptoms. 
The Plan denied your request. The Plan says enrollees 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 had network providers 
available who could have provided 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 outpatient office visit (99214) hospital 
outpatient clinic visit (G0463) and radiologic examination, chest (71046) provided on November 9, 2021 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of subcutaneous cardiac rhythm monitor 
(33285). 
 
You asked the Plan to pre-approve insertion of subcutaneous cardiac rhythm monitor (33285). You say that the 
requested insertion of subcutaneous cardiac rhythm monitor (33285) is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested insertion of subcutaneous 
cardiac rhythm monitor (33285). 
 
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 insertion of subcutaneous cardiac 
rhythm monitor (33285). Our reviewer says that the enrollee does not meet criteria for the requested insertion 
of subcutaneous cardiac rhythm monitor (33285). Our physician reviewer found while the enrollee has a 
history of atrial fibrillation and catheter ablation, there is no documentation provided to suggest a history of 
unexplained syncope, cryptogenic stroke or any other apparent indication for an implantable loop recorder 
(ILR). In summary, there is insufficient documentation to support the medical necessity for insertion of an ILR 
in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of subcutaneous cardiac rhythm monitor (33285) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion of subcutaneous cardiac rhythm 
monitor (33285).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care.  The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There 
are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level 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 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 the pathology services rendered on July 23, 2021. 
 
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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that radiology and other diagnostic services furnished to 
hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital.  
 
We looked at the file and Medicare rules. The file shows that the diagnostic services were furnished to a 
hospital outpatient. Payment is included in the payment to the hospital. Therefore, we decided that the Plan 
does not have to pay for the pathology services rendered on July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive sacroiliac joint fusion. 
 
You asked the Plan to pre-approve minimally invasive sacroiliac joint fusion. You say that the requested 
minimally invasive sacroiliac joint fusion is medically necessary. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for the requested minimally invasive sacroiliac joint fusion. 
 
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 minimally invasive sacroiliac joint 
fusion. Our reviewer says that the enrollee does not meet criteria for the requested minimally invasive 
sacroiliac joint fusion. Our physician reviewer found there is a history of degenerative lower back pain. There 
are no imaging studies showing sacroiliac joint instability, fracture, lesion, or severe degenerative joint disease. 
The requested fusion procedure is not medically needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of minimally invasive sacroiliac joint fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve minimally invasive sacroiliac joint fusion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 15, 
2021. 
 
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 these claims are automatically denied. 
 
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 81479 is not supported in the medical record. Specifically, this code was billed with 
modifier GZ. This means that the provider expected that it would not be considered medically necessary. These 
claims will be automatically denied. 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 laboratory services 
provided to the enrollee on November 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on 
November 29, 2021. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that you are requesting to 
reconsider the denial of this service. The Plan denied your request. The Plan says there was no referral and/or 
prior authorization for the out-of-network services. 
 
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 had network providers 
available who could have provided 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 subsequent nursing facility care visit provided 
on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit on November 3, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 had network providers 
available who could have provided the office visit at issue in this appeal. The Plan did not pre-approve the 
office visit 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 office visit on November 3, 2021, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on February 1, 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 that Current Procedural Terminology (CPT) code 29822- AS 59 (1 Unit) remains 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 29822 is "Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral 
bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor 
complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial 
bursa, foreign body[ies])." 
 
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 supported by the medical records. Our reviewer found the enrollee was being treated for 
complete rotator cuff tear or rupture of the left shoulder; impingement syndrome of the left shoulder; superior 
glenoid labrum lesion of the left shoulder; and strain of muscle, fascia, and tendon of other parts of biceps, left 
arm. The 2/1/22 operative report was for left shoulder arthroscopy with rotator cuff repair; soft tissue 
subacromial decompression and bursectomy; debridement of degenerative SLAP lesion; and resection of 
residual biceps stump. The procedure itself corroborates that there was a debridement of the biceps anchor-
grade 1 SLAP lesion performed on 2/1/22. This was prior to the rotator cuff repair having been performed. 
Therefore, the records do show that the above service (CPT 29822-AS 59- arthroscopy, shoulder surgical; 
debridement, limited, 1 or 2 discrete structures {e.g., humeral bone, humeral articular cartilage, glenoid bone, 
glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the 
rotator cuff, bursal side of rotator cuff, subacromial bursa, foreign body[ies]}) was a separate and distinct 
procedure from CPT- 29827- arthroscopy, shoulder surgical; with rotator cuff repair. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services provided to the enrollee on February 1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiac screenings coded as 81405, 81404, 
81403 and 81401 provided October 21, 2021. 
 You asked the Plan to pay for the laboratory service. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says screening 
genetic testing is not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory service, 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 hereditary cardiac screenings coded as 81405, 81404, 81403 and 81401 provided October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on October 25, 2021. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the 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 looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing (0037U) provided on October 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 10, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 an office visit provided on February 10, 2022 by 
an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health Services provided on January 11, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health Services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received in-network. 
 
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 had network providers 
available who could have provided 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 home health Services provided on January 11, 
2022 by an out-of-network (OON) provider.