Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that acute inpatient rehabilitation is medically necessary. 
The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about 
the enrollee's condition they 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 enrollee was admitted to an acute hospital on September 19, 2022, with a 
diagnosis of hemorrhagic shock, acute blood loss anemia, rectus femoris hematoma, deep vein thrombosis and 
had a IVC filter placed. The enrollee was recently admitted to a skilled nursing facility when he had a 
hemorrhagic shock and bilateral femoral shaft fractures. The enrollee is medically stable. While the enrollee 
has a need for physical or occupational therapy, the rehabilitation needs can be safely provided in a lower 
intensity and alternate setting such as in the skilled nursing facility with a similar outcome. 
 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need physical therapy, so you do not 
lose the ability to walk. The Plan denied your request. The Plan says the enrollee's medical needs are being met 
in the current acute setting. The LTACH would add no additional services. With additional time in the current 
setting, clinical stability can be ensured such that the appropriate lower level of care can be determined. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving with current treatment and 
should only require short-term additional acute care services that can be safely administered at the current 
facility until more stable and appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary at this time as it would not be clinically advantageous. Completion of treatment at the 
current facility is recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care facility visit on May 28, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care facility visit. You say that you feel this service 
should be covered and the copayment should be waived. The Plan denied your request. The Plan says the cost 
share has been applied 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 $30 
copayment for each Medicare-covered urgent care facility visit.  
 
 
 
 
 
 
 You have been asked to $30 for an urgent care facility visit. An urgent care facility visit falls within the 
Urgently Needed Services 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 an urgent 
care facility visit on May 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70552. 
 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 70544 is a column II code to column I code 70552. 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 70544 
billed for date of service May 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service February 2, 
2022. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says modifiers are not 
allowed with this code pair. 
 
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 93042 is a column II code to column I code 99291 with a modifier 
indicator of 0. The column II code is therefore not payable. 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 93042 
billed for date of service February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure received clearance from 
the Food and Drug Administration in 2016. You also say that this procedure is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested procedure is not medically necessary. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested procedure is considered experimental for back pain and therefore 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diagnostic injection provided on 
March 15, 2022. 
 
You asked the Plan to waive the coinsurance for the diagnostic injection. You say that the charge seems 
excessive for the marker fluid. 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 20% 
coinsurance for medical supplies, including chemical agents used in certain diagnostic procedures. 
 
You have been asked to pay 20% coinsurance for the diagnostic injection. This item/service falls within the 
medical supplies, including chemical agents used in certain diagnostic procedures 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.  The allowed amount for the diagnostic injection is $10,778.98. The 20% coinsurance for this amount is 
$2,155.80. Therefore, we decided that the Plan does not have to waive the coinsurance for the diagnostic 
injection provided on March 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete capsulectomy and includes the removal of all 
intra-capsular contents (19371) provided March 17, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that attached is the operative report or 
documents which details the services, and which should provide proof of necessity. The Plan denied your 
request. The Plan says the procedure code is inconsistent with the modifier used. Multiple physicians/assistants 
are not covered in this case. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 19371. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for a complete 
capsulectomy and includes the removal of all intra-capsular contents (19371) provided March 17, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 16, 2022.   
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations, and the date of consultations in the patients medical record. There 
was no documentation of contact in the patient record. 
 
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 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 psychotherapy provided on March 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging (78816). 
 
You asked the Plan to pre-approve a PET scan with CT. You say that the PET scan is medically necessary for 
his staging disease. The enrollee has not had a prior PET scan. The Plan denied your request. The Plan says 
there is no clinical information to support an additional CT PET scan ordered on 09/13/22. The request is 
therefore denied as not reasonable and necessary. 
 
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 with CT. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has melanoma. The record indicates that a PET scan was approved on August 31, 2022. The record does not 
provide results of this test or indicate that it was not performed. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service at this time. The 
elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
 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 with CT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) for attenuation correction and anatomical localization imaging (78816).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99204) provided on November 24, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code 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. 
 
In this case, the CPT Code Manual definition of code 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, records do not show the 
enrollee was a new patient. There were previous visits with the same physician group and specialty in the 
previous 3 years. 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 
(99204) provided on November 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on December 4, 2021. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis code was appropriate. The Plan 
denied your request. The Plan says a valid diagnosis was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 76882 was billed with diagnosis code R10.0. The billed diagnosis code is not included 
in those that support medical necessity.  Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the radiology services provided on December 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
11, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you would like this covered 
and waived as it was for covid related issues. 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 ambulance services. 
 
 
 
 
 
 
 You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the 
ambulance services 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 ambulance services 
provided on February 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that you were told 
there wouldnt be a copayment for this test. 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 $75 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. 
 
 
 
 
 
 You have been asked to pay a $75 copayment for magnetic resonance imaging (MRI). This item/service falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and 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 to waive the copayment for magnetic resonance imaging (MRI) provided on April 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on May 10, 
2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you should not be 
responsible to pay this. 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 $90 
copayment for emergency care. 
 
 
 
 
 
 
 
 You have been asked to pay a $90 copayment for emergency room visit. This item/service falls within the 
emergency care 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 emergency room visit 
provided on May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested Vertiflex 
procedure is considered experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is an 87-year-old female being treated for spinal stenosis of the 
lumbar region with neurogenic claudication. The pain is rated at 10/10 and is in the lower back and radiates 
down into her left leg to her toes. In this case, current evidence based medical guideline and peer reviewed 
literature do not fully support the spinal decompression device procedure over the gold standard of lumbar 
laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
the Vertiflex device for this enrollees medical condition. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
request for Vertiflex Superion interspinous device at L3-4 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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 24, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you think the bill was written 
incorrectly. 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 $45 
copayment for Physician/Practitioner services, including doctors office visits. 
 
 
 
 
 
 
 You have been asked to pay a $45 copayment for a specialist visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 specialist visit provided on November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric hospital bed. 
 
You asked the Plan to pre-approve the hospital bed. The Plan denied your request. The Plan says this is a 
replacement bed and is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have electric hospital bed. electric hospital bed serves the same purpose as the hospital 
bed. As your current hospital bed is within its reasonable useful lifetime, a replacement is not covered. 
Therefore, we decided that the Plan does not have to pre-approve an electric hospital bed.