Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on 
February 24, 2020. 
  You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services 
incident to a physician/non-physician practitioner's service must meet all incident requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical 
therapist on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services provided on January 27, 
2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 

 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim lists a place of service as an independent laboratory. The records provided do not indicate the 
services were provided at an independent laboratory. Based on this information, we decided that Medicare rules 
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the definitive drug testing services provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening testing provided on 
March 13, 2021.  
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the screening 
testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that the testing was ordered to determine if the enrollee has a gene mutation. Predictive testing 
without signs or symptoms is not a covered benefit. The testing services were requested for screening purposes. 
Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have 
to pay for the hereditary cardiovascular screening testing provided on March 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (93313) provided on May 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93313 
is a column II code to column I code 00567. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (93313) provided on May 
27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) spinal canal and 
contents (72148). 
 
You asked the Plan to pre-approve the MRI. You say that a new lumbar MRI will help evaluate progression of 
any pathology, comparing it to the last lumbar MRI and help guide further treatments. Please reconsider 
approving the lumbar MRI without contrast. The Plan denied your request. The Plan says the requested service 
does not meet medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has low back pain and has had variable relief to injection. 
The record references a previous MRI but no results are provided. The record does not indicate any change in 
neurologic examination. A consultation with a neurosurgeon is planned but not completed at this time. The 
requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's 
clinical condition 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) spinal canal and contents (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on June 17, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says chiropractic services not related to manual manipulation of the spine 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on 
December 10, 2020. 

You asked the Plan to pay for the testing services. You say that the treatment was necessary based on the 
enrollee's condition. The Plan denied your request. The Plan says Medicare denies coverage for all 
cardiovascular risk assessment testing panels for suspected or documented cardiovascular disease. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing services were requested for screening purposes. Medicare does not cover this testing for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening 
panel provided on December 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on February 15, 2021. 
 
You asked the Plan to pay for the critical care services. You say that you are providing supporting 
documentation and are requesting immediate payment for the care provided plus applicable late penalty fees. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 14, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the critical care 
services provided on February 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery (66821) provided on April 8, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this procedure code/type of bill is 
inconsistent with the place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 66821 is discission of secondary membranous cataract 
(opacified posterior lens capsule and/or anterior hyaloid); laser surgery (e.g., YAG laser) (1 or more stages). 
 
 We find that CPT code 66821 is not supported in the medical record. Specifically, this code was billed as 
occurring in a skilled nursing facility, but the medical records indicate this was a surgery center. Based on this 
information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, 
we decided that the Plan does not have to pay for the cataract surgery (66821) provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92004), and determination of refractive state 
(92015), provided on June 23, 2021. 

 You asked the Plan to pay for the eye exam, and determination of refractive state. You say that the services 
should be covered. The Plan denied your request. The Plan says routine eye exam services, for the purposes of 
prescribing glasses, when the member has not had cataract surgery, are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the eye exam (92004), and determination of refractive state 
(92015), provided on June 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Krystexxa (pegloticase), 1MG injection (CPT code 
J2507), for the enrollee. 
 
You asked the Plan to pre-approve the medication. You say that this is being used to treat gout. The Plan 
denied your request. The Plan says they did not receive chart notes showing failure of a ninety (90) day 
continuous trial of Uloric/febuxostat (if Uloric/febuxostat is contraindicated, failure of a 90-day continuous 
trial of probenecid dosed at 500mg time a day), a serum uric acid level greater than 6 MG/dL, and Glucose-6-
phosphate dehydrogenase (G6PD) deficiency results. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the medication. Our physician reviewer 
found the documentation does not sufficiently support that the Krystexxa (pegloticase), 1MG injection (CPT 
code J2507) is medically reasonable and necessary for the enrollee. The provided records show that Uloric is 
contraindicated for those with significant cardiovascular disease such as this enrollee as it can increase risk of 
cardiovascular (CV) death, but there was no contraindication to or failed trial of probenecid. Also, congestive 
heart failure (CHF) worsening risk is possible with Krystexxa. Also not provided was results of uric acid level 
above 6 mg/dL and normal G6PD. The documentation does not support that the Krystexxa would likely be safe 
and effective for the enrollee compared to probenecid which is likely to provide a reduced risk profile 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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Krystexxa (pegloticase), 1MG injection (CPT 
code J2507), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no movement problem that restricts normal activities in the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation does not support that you have a mobility limitation that significantly impairs the ability to 
participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, 
grooming, and bathing in customary locations within the home.  
 The documentation does not reveal that the patient's mobility limitation cannot be sufficiently and safely 
resolved by the use of an appropriately fitted cane, manual wheelchair or walker. The documentation does not 
reveal that the use of the wheelchair will significantly improve the patient's  mobility-related activities of daily 
living. The patient additionally is noted to have cognitive deficits therefore it is unclear if he can safely operate 
the power operated vehicle. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (J3301, 20610, 99214) provided on May 10, 2021.

You asked the Plan to pay for these medical services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says these claims have denied correctly.

The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services in question were corroborated by the medical records. Therefore, we decided that the Plan does not have to pay for the medical services (J3301, 20610, 99214) provided on May 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision procedure billed for services provided on May 
17, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code is not 
supported in the documentation. 
 
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 11642 is Excision, malignant lesion including margins, 
face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm. We find that CPT code 11642 is not supported in 
the medical record. The records provided do not show that the most comprehensive code describing the 
services provided were billed.  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 excision procedure billed for services 
provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up 
to and including 300 pounds (CPT code K0800). 
 
You asked the Plan to pre-approve the POV. You say that you have severe nerve damage and massive 
weakness resulting from a fall in 2018 and currently, you cannot get around in your home without a mobile 
device. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the POV have not been met. Review of the file shows that you are 
able to ambulate at a limited community level (1-2000ft). In addition, your weight (325lbs) exceeds the weight 
limit for the requested power scooter which is 300 pounds and described in the CPT code. Therefore, we 
decided that the Plan does not have to pre-approve the POV, group 1 standard, patient weight capacity up to 
and including 300 pounds (CPT code K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you have not tried and failed the preferred step therapy devices. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary. You have not tried and failed Orthovisc and Monovisc. There is 
no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects 
for you. Our physician reviewer found that your condition does not meet step therapy criteria for Gel-One. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
June 1, 2020, through June 20, 2020, billed with code KAXE1. 
 You asked the Plan to pay for the SNF services as billed. You say that the documentation supports the services 
as originally billed. The Plan denied your request. The Plan says there is no documentation presented that 
supports the diagnoses of malnutrition or risk for malnutrition. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare rules say that SNF services are billed using 
a HIPPS code which has four digits for four case-mix groups as described in the Medicare rules section. 
 
Calculation of the proper HIPPS code takes into account the Resident Assessment Instrument (RAI) manual 
and PDPM calculation worksheet, which provides guidance on completing the Minimal Data Set (MDS) 
assessment. Reported diagnoses in Section I of the MDS assessment are used to help determine both the 
nursing case-mix group (third digit of the HIPPS code) and NTA case-mix group (fourth digit). 
 
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 SNF services as billed. Our reviewer 
says that the documentation does not support the diagnoses of malnutrition or risk for malnutrition. Our 
physician reviewer found the enrollee is an 87-year-old woman with a history of heart disease, metastatic 
ovarian cancer, and hypertension. The enrollee had severe chemotherapy-induced peripheral neuropathy, and 
inability to ambulate. Documentation on 5/16/2020 includes "Digestive: Impaired nutrition - Monitor intake to 
facilitate healing, participation in therapy." Regarding diet, it is documented, "will keep for now and discuss 
with patient". A regular diet was ordered. There is insufficient documentation to support the billed diagnosis of 
malnutrition or risk for malnutrition for this enrollee for the period 6/1/2020 through 6/19/2020. 
 
We looked at this physician's review, the file, and Medicare rules. Since these diagnoses are not supported,  the 
billed HIPPS code is not supported. Based on this information, we decided that Medicare rules for coverage of 
the SNF services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
skilled nursing facility (SNF) services provided from June 1, 2020, through June 20, 2020, billed with code 
KAXE1.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from 
November 10, 2021, forward. 
 
You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that you are not ready 
to be safely discharged. Without proper treatment plans to help you, you could be a possible danger to yourself 
and others around you. The Plan denied your request. The Plan says under Medicare, the request is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 continued inpatient psychiatric 
admission. Our reviewer says that a continued inpatient psychiatric admission from November 10, 2021, 
forward is not medically necessary. Our physician reviewer found you do not appear to require inpatient mental 
health treatment beyond the date in question as you are not a danger to herself or others, no auditory 
hallucinations or visual hallucinations while being cooperative with treatment. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services were reasonably 
expected to improve your condition or were for the purpose of diagnosis beyond the date in question. Based 
upon review of the records provided for the admission, you do not meet the criteria for continued acute 
inpatient mental health treatment from November 10, 2021, forward as you were not shown to be a danger to 
yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant 
with treatment. You were not showing any aggressive behaviors, or any treatment required for acute threats of 
safety. 
 
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 continued inpatient psychiatric admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from November 
10, 2021, forward.