Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy home health visits 
(G0151). 
You asked the Plan to pre-approve additional physical therapy visits. You say that the requested services are a 
medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the 
requested services have not been met. 
 
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 physical therapy visits. Our 
reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation doesn't support that you require additional skilled rehabilitation services 
to provide treatment that is medically necessary. You do not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance 
program to maintain your condition, and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 16 additional physical therapy home health visits (G0151).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on November 1, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing is medically necessary to 
successfully treat the enrollee. The Plan denied your request. The Plan says urine drug tests that are not used in 
the management of the enrollee is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation 
 
We find that the drug testing provided is not supported in the medical record. The records do not show that the 
testing was ordered based on the enrollees history, clinical assessment, or a change in behavioral pattern. 
Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on 
November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on September 23, 2021. 
 
You asked the Plan to pay for these services. You say that the plan website shows that the provider is an 
approved provider. The Plan denied your request. The Plan says the services are not covered when performed 
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 is not manual manipulation of the spine. The file shows that the 
chiropractor submitted a claim for procedure codes 72050 (cervical spine x-ray), 72100 (lumbosacral spine x-
ray), and 99203 (office visit). Therefore, we decided that the Plan does not have to pay for the chiropractic 
services rendered on September 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sleep study (CPT code 95806) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the sleep study. You say that the process of coming in through the transport 
van from East County to your San Diego main location is cumbersome and painful and requires two (2) 
separate trips for this test. You state to please consider allowing the enrollee to have a mail-in test option 
through the requested provider for their home unattended sleep study which would allow this process to be 
much more feasible. The Plan denied your request. The Plan says such service is available in-network. The 
Plan states there are no extenuating circumstances related to geographic access, compelling continuity of care 
making it medically necessary that future care come only from this provider, or unique medically recognized 
qualifications of the requested out-of-network provider to justify prior authorization of out-of-network benefits. 
 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. Therefore, we decided that the Plan does not have to pre-approve 
the sleep study (CPT code 95806) to be provided by an out-of-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tildrakizumab 1MG injection (CPT code J3245). 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessity for the enrollee's 
treatment for psoriasis. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred step therapy drug(s): Stelara. The Plan states there is no indication the Plan's preferred drug(s) would 
likely be: less effective, and/or cause adverse effects for the enrollee. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found based on the medical records provided the enrollee has not tried and failed the required drug(s). There is 
no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects 
for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tildrakizumab 1MG injection (CPT code J3245).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 82310, 82728, 83540, 
83550, and 84100) provided on August 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Laboratory testing related to treatment of end-stage renal disease is bundled into dialysis services and is not 
separately reimbursable. The documentation submitted showed that the laboratory tests reported were related to 
treatment of ESRD since end-stage renal disease was indicated as a reason for the laboratory tests, and a 
separate professional visit unrelated to ESRD was not indicated in the medical record. Therefore, the laboratory 
tests are included in the dialysis services. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services (CPT code 82310, 82728, 83540, 83550, and 84100) provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from November 13, 
2020, to November 19, 2020. 
 You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of the secondary diagnosis code G93.41 with DRG 689. The Plan denied your request. The Plan says the 
medical records do not support the billing of the secondary diagnosis code G93.41 with DRG 689. 
 
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 G93.41. 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 inpatient hospital services. Our reviewer says that the medical records do not 
support the billing of the secondary diagnosis code G93.41 with DRG 689. Our physician reviewer found the 
review indicates that the discharge summary documented that the enrollee had confusion during hospital stay 
even after treatment of urinary tract infection, and "Oriented to person, place time but lacks awareness and/or 
orientation to current situation in terms of her medical condition". Occupational therapy documentation: 
daughter of enrollee reports "Her short-term memory has been impaired since her second cerebral vascular 
accident (CVA)." History of present illness (HPI) documentation states "She is directly admitted to the 
hospitalist service where she is stable and has no obvious neurological deficits." Physical exam findings during 
admission consistently documented alert and oriented X 3. The enrollee was discharged to Rehab facility, 
"clearly has issues with memory possibly executive function and cannot make medical decisions for herself at 
this present time." These findings are not evidence of an acute process of encephalopathy in which one would 
expect improvement in symptoms with treatment. As noted above, although the provider documented 
metabolic encephalopathy, reasonable support within the health record was not present in the medical record. 
The review has determined that the medical records did not support the billing of the secondary diagnosis code 
G93.41 with DRG 689.  
 
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 the inpatient hospital services provided from November 13, 2020, to November 19, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation 
(76377) provided on May 5, 2021. 
 
You asked the Plan to pay for code 76377. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan references Local Coverage Article (LCA) A56526; however, this LCA 
is not binding for the state of Michigan where the services were performed. The Plan has not provided any 
valid Medicare rules or documentation to support that the 3D rendering is not payable. Therefore, we decided 
that the Plan has to pay for the 3D rendering with interpretation and reporting of computed tomography, 
magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under 
concurrent supervision; requiring image postprocessing on an independent workstation (76377) provided on 
May 5, 2021.  
 
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 pay for the surgical dressings provided on November 16, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON dressings. You say that the Plan must cover these dressings because 
they are covered by Medicare. The Plan denied your request. The Plan says the dressings were provided in a 
non-emergency situation by an OON provider. No authorization for this provider 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 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 surgical dressings provided on November 16, 
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 the services (71045) provided on December 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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, we have confirmed that code 71045 
is a column II code to column I code 74022. 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 the services (71045) provided on December 7, 2021.
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 IRF care will provide strategies for mobility and 
promote a safe discharge disposition. The Plan denied your request. The Plan says an intensive rehabilitation 
program is not medically necessary. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 You asked the Plan to pre-approve the compression stockings. You say that you need the compression socks 
with straps because you have problems with your shoulders and hands. You also say that you do not have the 
strength to put on stockings. The Plan denied your request. The Plan says the requested item is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6549.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pelvic angiography rendered on November 19, 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 rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 75736 (pelvic angiography) and 37243 (vascular 
embolization). Code 75736 is a column II code with a modifier indicator of 1 when billed with column I code 
37243. Code 75736 was not billed with an appropriate modifier to allow for separate payment. Therefore, we 
decided that the Plan does not have to pay for the pelvic angiography rendered on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says facet joint injections are not medically necessary. 
 
The Plan follows Medicare rules. 
 
 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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that the enrollee has 
multiple other pain generators at the proposed level of facet injections. Therefore, the request does not meet the 
criteria of the LCD and is deemed 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code K0553) and 
receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT code K0554) 
provided on October 26, 2021. 
 
You asked the Plan to pay for the supplies. You say that the claim should be paid. The Plan denied your 
request. The Plan says the supplies are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the supplies have not been met. The documentation submitted did 
not sufficiently support the billed supply code. Therefore, we decided that the Plan does not have to pay for 
supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 
month supply = 1 unit of service (CPT code K0553) and receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (CPT code K0554) provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by out-of-network providers and 
opt-out-providers on April 13, 2021, to December 6, 2021. 
 
You asked the Plan to pay for dental services. You say that the Plan should pay for this. The Plan denied your 
request. The Plan says the rendered dental services are not covered dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services provided by out-of-network providers and opt-out-providers on April 13, 2021, to December 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent stretcher van transportation services (T2005, 
A0380, A0999) provided on December 12, 2021. 
 
You asked the Plan to pay for the stretcher van transportation. You say that these services were provided in 
good faith and should be paid. The Plan denied your request. The Plan says these services are not covered by 
Medicare or by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for stretcher van transport 
services. In addition, Medicare rules say that providers must report services correctly. Providers must report 
services with the appropriate CPT code. 
 
The services you have asked the Plan to pay for are non-emergent stretcher van transport services. In addition, 
CPT codes T2005 and A0380 both have a Status Indicator of I on the Physician Fee Schedule. This means that 
CPT codes T2005 and A0380 are not valid for Medicare purposes. CPT code has a Status Indicator of X on the 
Physician Fee Schedule, which means that this code is not eligible for payment. Therefore, we decided that the 
Plan does not have to pay for non-emergent stretcher van transportation services (T2005, A0380, A0999) 
provided on December 12, 2021.