Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a subcutaneous cardiac rhythm monitor (implantable 
loop recorder) (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the enrollee has already had a 3 
week monitor and is qualified for the loop. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for coverage, as they have not had syncope. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related, but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom 
MLR. 
 
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 an implantable loop recorder. Our 
reviewer says that there is insufficient documentation to support the medical necessity for insertion of an ILR 
in this enrollees clinical management. Our physician reviewer found while the enrollee has documented salvos 
of supraventricular tachycardia, there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke, or any other apparent indication for an ILR. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a subcutaneous cardiac rhythm monitor (implantable loop recorder) (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88360 and 88381 billed for date of service 
March 15, 2022. 
 
You asked the Plan to pay for procedure codes 88360 and 88381. You say that the claim was billed correctly. 
The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88360 and 88381. This means there is 
both a professional and technical component for the CPT codes. In this case, an appropriate modifier to indicate 
the professional component has not been billed with the codes. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 88360 and 88381 billed for date of service March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) 
(eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 
needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging 
guidance (ie, fluoroscopy or CT) (CPT code 62323). 
 
You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the enrollee's records do 
not show documentation of at least 50% sustained improvement in pain for at least three (3) months duration 
before a second block. The Plan states the enrollee's records indicate that they had an injection in August 2022 
and have not been seen by this requesting provider since. 
 
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 injection. Our physician reviewer 
found there is no follow-up documentation of the degree and duration of pain relief provided from the first ESI. 
Therefore, a second injection cannot be endorsed since there is no data presented. The request is considered not 
medically 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, 
opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, 
interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or 
CT) (CPT code 62323).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient Hospital Care provided on July 
16, 2022, to July 18, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient Hospital Care. You say that you disagree with the 
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. Your 
contract with the Plan says that there is a 10% coinsurance which applies to out-of-network inpatient Hospital 
Care.  
 
The item or service you asked the Plan to waive the coinsurance for falls within the out-of-network inpatient 
Hospital Care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a 10% coinsurance which applies to out-of-network inpatient Hospital Care. The total allowed amount 
for the inpatient care is $4,616.62. Your deductible amount is $246 ($4,616.62 - $246 = $$4,37062). You are 
being asked to pay $437.06 ($4,370.62 x 10% =$437.06). This cost sharing is a contractual obligation that had 
not been met at the time inpatient Hospital Care was received on July 16, 2022, to July 18, 2022. Therefore, we 
decided that the Plan does not have to waive the coinsurance for inpatient Hospital Care provided on July 16, 
2022, to July 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON cataract surgery. You say that the enrollee recently had his right 
eye cataract surgery done and had no issues getting authorization from insurance. You say that he now needs 
his left eye cataract surgery done to even out his vision and help him see clearer. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria to be seen by an OON provider, as there are providers in-
network who can perform the services being requested. 
 
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 
cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for venous blood collection (G0471) provided on March 28, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for venous blood collection. You say that the enrollee does not come to the lab for 
this service. The Plan denied your request. The Plan says the OON lab service was referred by an OON 
provider and performed without prior authorization. 
 
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 venous blood collection (G0471) provided on 
March 28, 2022, 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 injection (20610), and fluoroscopic guidance for needle 
placement (77002) provided on December 15, 2021. 
 
You asked the Plan to pay for the injection. You say that the services should be covered. The Plan denied your 
request. The Plan says the injection 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 injection. Our reviewer says that the 
injection was not considered medically reasonable and necessary in this case. Our physician reviewer found the 
provided documentation does not indicate that the physical therapy was completed. The reviewer found that you completed a series of injections on July 1, 2021. Therefore, the reviewer found that the injection was 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the injection (20610), and fluoroscopic guidance for needle placement (77002) provided on 
December 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for six units of procedure code 99292 billed for date of service 
June 2, 2022. 
 
You asked the Plan to pay for six units of procedure code 99292. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says these services are not supported in the 
medical record, as the time spent providing critical care is not noted. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the total time spent 
providing critical care is not noted in the record. Without this information, it cannot be confirmed that the use of this add-on code is appropriate, and the number of units cannot be verified. Based on this information, we 
decided that Medicare rules for coverage of six units of procedure code 99292 have not been met. Therefore, 
we decided that the Plan does not have to pay for six units of procedure code 99292 billed for date of service 
June 2, 2022.
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 you are not able to do daily things and need help to 
move around. The IRF will help you to gain strength to be able to support yourself. The Plan denied your 
request. The Plan says your current level of function does not require an intensive, complex, multidisciplinary 
approach to daily therapy. 
 
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 your medical records do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided in South Carolina on March 24, 
2022. 
 
You asked the Plan to pay for office visit. You say that you experienced a burning sensation in your mouth and 
bad taste for several days, so went to the closest urgent care. The Plan denied your request. The Plan says the 
record does not support that this service was urgently needed. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 office visit. Our reviewer says that this visit does not meet criteria for payment. Our physician reviewer found you could not have foreseen the need for this 
service prior to leaving the Plan service area and this visit was medically necessary. However, it would have 
been medically reasonable to delay the service until you returned to the Plan service area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit provided in South Carolina on March 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery 
(22869). 
 
You asked the Plan to pre-approve the surgery. You say that the enrollee demonstrates to be a good candidate 
because there is no radiographic evidence of instability, no remarkable scoliosis or severe osteoporosis. The 
Plan denied your request. The Plan says a review of the applicable guidelines does not support the use of this 
device for long term relief of back and leg pain and there are currently no clinical indications for this 
technology. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (22869).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity study (93925). 
 
You asked the Plan to pre-approve a lower extremity study. The Plan denied your request. The Plan says there 
is no documentation of any concerns for limb ischemia or peripheral arterial disease. The Plan also says the 
lower extremity duplex scan is not reasonable or necessary at this time. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
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 lower extremity study. Our reviewer 
says that there is insufficient documentation to support the medical necessity for lower extremity arterial 
ultrasound examination in your clinical management. Our physician reviewer found the enrollee has evidence 
of mild aortic and carotid plaquing, but there is no history of claudication. Our reviewer found that there are no 
symptoms or signs of limb ischemia.   Our physician reviewer also found that the guidelines for lower 
extremity arterial ultrasound examination are not met. 
 
 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 lower extremity study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lower extremity study (93925).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01936 provided on November 23, 2021. 
 
You asked the Plan to pay for procedure code 01936. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 19, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 01936 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 01936 provided on November 23, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy (97760, 97535, 97530, 97112, 
97750, 97110, 97140, G0283, 97014, 97010, 97035, 97022, 97018, 97033, 97034, 97761, and 97168). 
 
You asked the Plan to pre-approve the therapy services. You say that your arm is finally making improvements 
and you need additional therapy. The Plan denied your request. The Plan says the notes show that the request 
for further occupational therapy was not certified by your provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the 
supervision of a therapist. The additional visits are not medically necessary for a chronic condition with deficits 
and are not reasonable. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve occupational therapy (97760, 97535, 97530, 97112, 97750, 97110, 97140, 
G0283, 97014, 97010, 97035, 97022, 97018, 97033, 97034, 97761, and 97168).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found there is no evidence this has been tried and demonstrated to fail as an outpatient. Medicare does 
not cover a home ventilator when used as bilevel positive airway pressure (BiPAP). Battery backup and alarms 
are not required for this 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).