Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee was admitted due to difficulty in 
walking, he is currently receiving rehabilitative services. The Plan denied your request. The Plan says that SNF 
care is not medically necessary. 
 
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 SNF 
care is medically necessary. Our physician reviewer found that the enrollee does not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee 
does have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee requires daily skilled nursing and/or skilled therapy on an inpatient basis in 
a skilled nursing facility (SNF) setting. Provided records document a significant decline in the enrollees 
functional status compared to his recent baseline to necessitate daily inpatient skilled therapy services.  
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid. 
 
You asked the Plan to pre-approve Synthroid. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Synthroid.  
 
 
 Benefits for Synthroid may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. 
 
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: 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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there are no services available at the LTACH that you require that are not available 
and being provided at the health care setting being offered by the health plan. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological supervision and interpretation of a unilateral 
extremity angiography rendered on September 1, 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 procedure code 75710 is not separately payable. 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 75710 
is a column II code to column I code 75625. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met.  
 
In this case, the CPT Code Manual definition of code 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. 
 
We find that CPT code 75625 is not supported in the medical record. Specifically, there is no documentation of 
radiological supervision and interpretation of an abdominal aortography by seriolography. 
 
Therefore, we decided that the Plan does not have to pay for the radiological supervision and interpretation of a 
unilateral extremity angiography rendered on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
December 2, 2021. 
 
  You asked the Plan to pay for the moderate sedation services (99153). You say that the attached medical 
records support the services rendered. You say that the claim should be reviewed and reconsidered for 
payment. The Plan denied your request. The Plan says CPT code 99153 may not be paid if furnished to hospital 
inpatients or patients in a hospital outpatient department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a 
technical component only code and the claim indicates that this service was rendered in a facility setting. 
Payment for CPT code 99153 is made to the facility and is the responsibility of the facility to any physician or 
vendor. Based on this information, we decided that Medicare rules for coverage of the moderate sedation 
services (99153) have not been met. Therefore, we decided that the Plan does not have to pay for the moderate 
sedation services (99153) provided on December 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on February 9, 2022. 
 
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 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 76705 
is a column II code to column I code 93976. 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 abdominal ultrasound rendered on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
appliances (E0656, E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that there is no 
other supplier that can provide the same prescribed program to the enrollee. In-network pneumatic compression 
device treatment programs will not correlate nor be equivalent to the prescribed plan of care from 
the Flexitouch and cannot provide the same therapeutic action ordered by her doctor. The Plan denied your 
request. The Plan says there are in-network providers available to provide this service. 
 
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. The records provided for review do not 
show that the services at issue were urgent or emergent. 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 a pneumatic 
compression device (E0652) and appliances (E0656, E0667) to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a wheelchair power seat elevation system. You say that the item should be 
covered. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the spinal cord stimulator is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are subject to the criteria 
listed 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 a spinal cord stimulator trial. Our 
reviewer says that the requested spinal cord stimulator is not medically reasonable and necessary. Our 
physician reviewer found you are a 71-year-old woman with chronic low back pain. In this case, the patient had 
a successful treatment with an epidural steroid injection. A spinal cord stimulator is reserved for patients as a 
last resort. The patient has other options available at this time for managing her medical condition. The 
requested service is 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 a spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular procedure 
(95999) provided on May 24, 2021. 
 
You asked the Plan to pay for the unlisted neurological or neuromuscular procedure (95999). You say that the 
services were requested out of medical necessity by the surgeon and the surgeon has an authorization on file. 
You say that this claim should be approved if the surgeons claim was approved, and the claim should be 
reprocessed at the in-network benefit level. The Plan denied your request. The Plan says procedure code 95999 
is not supported by the medical records submitted. 
 
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 95999 is unlisted neurological or neuromuscular 
diagnostic 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 unlisted neurological or neuromuscular procedure 
(95999). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found that there is no documentation of the procedure that is being reported with an 
unlisted procedure code. Therefore, this procedure cannot be verified. 
 
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 unlisted neurological or neuromuscular procedure (95999) have not been 
met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular 
procedure (95999) provided on May 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection procedure for cystography (51600), 
cystourethroscopy (52001) and prostate resection (52601) provided on April 21, 2021. 
 
You asked the Plan to pay for the injection procedure for cystography (51600), cystourethroscopy (52001) and 
prostate resection (52601). You say that the medical records should be reviewed, and the claim considered for 
payment. The Plan denied your request. The Plan says procedure codes 51600, 52001 and 52601 are not 
supported by the medical records submitted. 
 
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 51600 is injection procedure for cystography or voiding 
urethrocystography. The CPT Code Manual definition of code 52001 is cystourethroscopy with irrigation and 
evacuation of multiple obstructing clots. The CPT Code Manual definition of code 52601 is transurethral 
electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, 
meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included). 
 
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 injection procedure for cystography (51600), 
cystourethroscopy (52001) and prostate resection (52601). Our reviewer says that the documentation submitted 
was reviewed and does not meet the criteria for coverage. Our reviewer found that the medical records do not 
include documentation of an injection procedure, cystourethroscopy with irrigation and evaculation of multiple 
obstructing clots or transurethral electrosurgical resection of prostate. Therefore, these procedures cannot be 
verified. 
 
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 injection procedure for cystography (51600), cystourethroscopy (52001) and 
prostate resection (52601) have not been met. Therefore, we decided that the Plan does not have to pay for the 
injection procedure for cystography (51600), cystourethroscopy (52001) and prostate resection (52601) 
provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you went to this appointment 
because you received a flyer from the Plan indicating you would go to this provider for a free consult and free 
glasses. You also say that you were turned away for the free glasses because the provider said you have 
cataracts. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $50 
copay for in-network physician services to diagnose and treat diseases and conditions of the eye.  
 You have been asked to pay a $50 copay for the eye exam. The eye exam falls within the Vision 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 the eye exam (92004) provided on November 
3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 12, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator provided on March 19, 
2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you disagree with the plan's 
denial. The Plan denied your request. The Plan says the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the automatic external defibrillator was not filed until March 22, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator provided on 
March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intermittent limb compression device (E0651) provided 
on October 27, 2021. 
 
You asked the Plan to pay for the intermittent limb compression device. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation 
submitted did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the medical records submitted did not include information that the provider discussed 
the need for the ordered equipment with the enrollee. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the intermittent limb compression device (E0651) provided on October 27, 2021.