Persius/hicric huggingface dataset:
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 criteria for admission to SNF have not been met. 
 
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/The enrollee] [do/does] not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. [You/The enrollee] [do/does] not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. [You/The enrollee] [do/does] not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy visits from November 18, 
2021, to January 19, 2022. 
 
You asked the Plan to waive the deductible for physical therapy visits. You say that you thought physical 
therapy was covered under your insurance. 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. Your 
contract with the Plan says that there is $5,000 deductible which applies to Outpatient rehabilitation services.  
 
  The item or service you asked the Plan to waive the deductible for falls within the Outpatient rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $5,000 deductible which applies to Outpatient rehabilitation services. This cost sharing is a contractual 
obligation that had not been met at the time physical therapy visits was received on November 18, 2021, to 
January 19, 2022. Therefore, we decided that the Plan does not have to waive the deductible for physical 
therapy visits from November 18, 2021, to January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the central motor evoked potential study, upper limbs 
(95928), somatosensory evoked potential study, upper limbs (95925), and needle electromyography (95860) 
provided on April 26, 2022. 
 
You asked the Plan to pay for the intraoperative neuromonitoring (IONM). You say that the services provided 
were to help surgeons with the iatrogenic injuries that can be sustained during surgery. You also say that the 
services were medically necessary. The Plan denied your request. The Plan says the services were 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 pay for the intraoperative neuromonitoring (IONM). 
Our reviewer says that the requested INOM were not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation indicates that the type of surgery the enrollee 
underwent on the date of service in this case is not one for which the applicable LCD supports the use of 
intraoperative neurophysiological monitoring. The reviewer found that the documentation does not indicate 
there was a major risk to major sensory or motor nerves associated with this procedure. Therefore, the reviewer 
found that the IONM services were 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 intraoperative neuromonitoring (IONM) have not been met. Therefore, we 
decided that the Plan does not have to pay for the central motor evoked potential study, upper limbs (95928), 
somatosensory evoked potential study, upper limbs (95925), and needle electromyography (95860) provided on 
April 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 77002 provided on May 19, 2022. 
 
You asked the Plan to pay for code 77002. You say that the service was medically necessary and billed with the 
appropriate modifier. The Plan denied your request. The Plan says an add-on code was billed without an 
acceptable primary procedure code. 
 
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 77002 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for code 77002 provided on May 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trodelvy. 
 
You asked the Plan to pre-approve Trodelvy. 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 may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Trodelvy. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Trodelvy is not FDA-
approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. The drug is currently being investigated in a 
phase III trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trodelvy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Trodelvy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridements provided on May 2, 2022. 
 
You asked the Plan to pay for debridements. You say that these services were reported correctly and are 
supported as billed. The Plan denied your request. The Plan says these codes are 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 97597 is debridement, open wound, total wound surface 
area first 20 square centimeters or less. The CPT Code Manual definition of code 97598 is debridement, each 
additional 20 square centimeters or part thereof. 
 
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 debridements. Our reviewer says that these codes do not 
meet criteria for payment. Our reviewer found the procedure report does not describe debridement. The 
procedure report documents: "Dressings clean dry and intact at time of my arrival.  Remove dressing and 
cleansed open areas with dermal cleanser for 10 minutes soak.  Applied barrier cream with steroids to all 
periwounds.  Bilateral heels layered with collagen, AG, super absorbent dressing.  Right lateral wound with collagen, AG, and gauze.  Bilateral legs wrapped with Unna boot, Kerlix, and Coban." Therefore, debridement 
cannot be verified as billed. As code 97598 is an add-on code for 97597 and the primary procedure code cannot 
be verified, the add-on code is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of debridements have not been met. Therefore, we decided that the Plan does not 
have to pay for debridements provided on May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial placement (63650 x 
2). 
 
You asked the Plan to pre-approve SCS placement. You say that you have previously received 6 epidural shots. 
You say that they were unsuccessful. You also say that this is medically necessary. The Plan denied your 
request. The Plan says the SCS is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that payment may not be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the 
conditions have been met. 
 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 SCS placement. Our reviewer says that 
the requested SCS placement are not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that you have tried and failed physical therapy, or injections. The reviewer 
also found that there was no neurosurgery consult notes provided. Therefore, the reviewer found that the 
requested SCS placement are not medically reasonable or necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SCS placement have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial placement (63650 x 2).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 21, 2022, to 
July 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from June 21, 2022, to July 
20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for LTACH care. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the current acute care hospital. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 20930 and 22853) 
provided to the enrollee on November 11, 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 the records do not support the services 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 the denied codes is: 
 CPT 20930: 
 
Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in 
addition to code for primary procedure) 
 
CPT 22853: 
 
Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation 
for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with 
interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) 
 
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 not supported by the medical records. Our reviewer found that in terms of CPT 22853, the 
medical records and operative note do not document an anterior structural device with anterior instrumentation- 
screw fixation. The 22853 code is not supported by the records and should be denied. 
 
Additionally, we find that procedure code 20930 has a status indicator of B on the Physician Fee Schedule. 
This means that procedure code 20930 is not separately payable. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure codes 20930 and 22853) provided to the enrollee on November 11, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 19, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that you have been seeing this provider for three years 
and when your insurance changed you did not realize you should check out this provider. The Plan denied your 
request. The Plan says a licensed professional counselor is not eligible to be reimbursed by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on  
July 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33419 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 33419. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 33419 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 33419 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 33419 billed for date of service August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (code 92015) provided on  
February 7, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you paid your $45 copayment and you were not 
assessed for any other procedure with this provider. The Plan denied your request. The Plan says your claim 
processed correctly. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury.  Therefore, we decided that the 
Plan does not have to pay for an eye refraction (code 92015) provided on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 14, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under an HMO Plan unless preauthorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74181 billed for date of service February 16, 
2022. 
 You asked the Plan to pay for procedure code 74181. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74181 is bundled into payment for 
code 74183. 
 
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 74181 
is a column II code to column I code 74183. 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 74181 billed for date of service February 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not recommended for staging, diagnosis, or to assess treatment response. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the treatment itself is not disputed in this case but rather the need for image guidance. There are no 
billing resources that allow for billing of G6001 at time of simulation. While historically imaging codes were 
billed separately at the time of simulation, necessary imaging at the time of simulation is now bundled into the 
simulation codes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound guided radiation therapy (US-IGRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 5, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document a necessity to perform a polymerase chain reaction (PCR) as 
opposed to a standard urinalysis, culture and sensitivity which is standard of care for a urinary tract infection.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on July 5, 2022.