Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on June 14, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are submitting documentation for review. 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) provided on 
June 14, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a coronary computed tomographic angiography (CCTA) 
(75574). 
 
You asked the Plan to pre-approve the CTA. You say that the requested service is to help with risk 
stratification. You say that the scan is necessary so the enrollee can see the results to help guide her into taking 
the medication. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a CCTA is not covered in the absence of symptoms. 
 
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 CTA. Our reviewer says that the 
requested CTA is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has any cardiac symptoms. Therefore, the reviewer found that the requested service is 
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 the CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a coronary computed tomographic angiography (CCTA) (75574).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says you can be treated in a lower level of care such as at home with caregiver. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you no longer qualify for SNF coverage. You do not have documented skilled 
nursing or skilled therapy needs. You appear to have reached a plateau in function. Daily skilled services are 
not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 
Your care needs can, as a practical matter, be provided in a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continued stay at skilled nursing facility (SNF).
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 services are not medically reasonable 
or necessary. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 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 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 low back pain, and was admitted to skilled nursing on 9/8/22. 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, and 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. There is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing visits in your home (G0299 x 
3). 
 
You asked the Plan to pre-approve additional home health visits. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says the additional home health 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 additional home health visits. Our 
reviewer says that additional home health visits are not medically necessary. Our physician reviewer found the 
provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 
The reviewer found that the records do not support that the enrollee requires skilled nursing care. Therefore, the 
reviewer found that additional home health 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 additional home health visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional skilled nursing visits in your home (G0299 x 3).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT) and image guided 
radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IMRT and IGRT. The Plan denied your request. The Plan says that IMRT 
and IGRT are not recommended. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 IMRT and IGRT. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the guidelines recognize hippocampal sparing IMRT as a consideration in the setting of 
prophylactic brain radiation. A randomized trial demonstrated a benefit. Our reviewer found that the data for 
other solid cancers shows a benefit with respect to qualify of life and neurocognition. Hippocampal-sparing 
whole brain radiation could feasibly considered to be in accordance with accepted standards of care for small 
cell lung cancer. Our physician reviewer also found that the treatment could be considered in accordance with 
the accepted standards, and therefore safe and effective and otherwise 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 IMRT and IGRT have been met. Therefore, we decided that the Plan has to pre-
approve intensity-modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee has already received an LDCT scan for 
lung cancer screening this year. A 6-month follow up study is not covered. Therefore, we decided that the Plan 
does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have pay additional reimbursement for the breast prosthesis and mastectomy 
bras provided on December 29, 2021. 
 
You asked the Plan pay additional reimbursement for the breast prosthesis and mastectomy bras. You say that 
you are appealing this cost-share 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 20% 
coinsurance for durable medical equipment.  
 
 
  You have been reimbursed $343.18 and the 20% coinsurance was applied correctly for the breast prosthesis 
and mastectomy bras. Additionally, shipping and handling is not covered by Medicare. This item/service falls 
within the Durable Medical Equipment (DME) and Related Supplies 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 pay additional reimbursement for the breast prosthesis and mastectomy bras provided on 
December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a urologist (99204) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the enrollee does not feel comfortable and 
confident with current urological providers that he has already seen. You also say that based on the enrollee's 
research, the requested provider is more qualified to perform the procedure on him. The Plan denied your 
request. The Plan says no medical necessity was found in the provided documentation that would indicate that 
the enrollee should see a tertiary level provider. The Plan also says the service was already approved with an 
in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 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. We found no exception that would require 
the Plan to pre-approve these items/services. The records show that the Plan has approved an office visit with 
an in-network provider. Therefore, we decided that the Plan does not have to pre-approve an office visit with a 
urologist (99204) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the Skilled Nursing Facility (SNF) services you and/or your provider 
are requesting do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that given the patient's worsening weakness and fatigue with an elevation in his white 
blood cell count, a metabolic acidosis with a respiratory alkalosis and a new opacity of chest radiographic 
imaging as well as the need for the intravenous bicarbonate drip and the phosphorous replacement, the patient 
does not appear to be medically stable for discharge from the acute hospital to a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99202 provided on May 17, 2022. 
 
You asked the Plan to pay for procedure code 99202. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99202 is not payable when 
billed by a chiropractor. 
 
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, procedure code 99202, is not manual manipulation of the spine. 
Therefore, we decided that the Plan does not have to pay for procedure code 99202 provided on May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the oxygen equipment purchased on July 
8, 2021. 
 
You asked the Plan to provide reimbursement for the oxygen equipment. You say that you feel that oxygen is 
reimbursable, so you are expecting to be paid for the equipment you purchased. The Plan denied your request. 
The Plan says Medicare does not cover the purchase of oxygen equipment. This equipment was purchased from 
a supplier that is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to provide reimbursement for the oxygen 
equipment purchased on July 8, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan (78815). 
 
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says that this request 
does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the 
PET scan should be approved for coverage. Our physician reviewer found the enrollee has evidence of 
hematogenous spread of tumor into the cerebellum and the most recent computed tomography (CT) of the 
chest, abdomen and pelvis taken on April 27, 2022, showed a new 1.3-centimeter solid renal lesion called a 
new neoplasm. Our reviewer also found that given the history and new findings on CT, the requested PET/CT 
is reasonable as a total body test for spreading tumor. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan (78815).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl (J0896). 
 
You asked the Plan to pre-approve Reblozyl. You say that you feel there will be a synergy when this drug is 
used with the enrollee's erythropoietin treatment. The Plan denied your request. The Plan says the requested 
drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Reblozyl. Our reviewer says that the 
requested drug, Reblozyl, is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee has ever required a blood transfusion. Therefore, the reviewer 
found that the requested drug is not medically reasonable or necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl (J0896).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 9, 2021, to October 12, 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 a DRG review was performed which resulted in the changing of the DRG from 418 to 419.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 418 (LAPAROSCOPIC 
CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC). 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 services at issue in this case were not supported by the medical 
records. Our physician reviewer found that after reviewing the hospital admission record, although pancreatitis 
is documented as a secondary problem, there is inconsistent and insufficient documentation to assign billary 
acute pancreatitis as the principal diagnosis, and a query should be made prior to billing. In this case, DRG 419 
would be more appropriate to report.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from October 9, 2021, to October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22845 billed for date of service April 12, 
2022. 
 
You asked the Plan to pay for procedure code 22845. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 22845 is bundled into payment for code 22853. 
 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, we have confirmed that code 22845 
is a column II code to column I code 22853. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 22845 billed for date of service April 12, 2022.