Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visits, care management services, and 
psychotherapy services provided from August 18, 2022, to October 10, 2022. 
 
You asked the Plan to reimburse you for the outpatient services. You say that the mental health services 
provided by this physician are critical. You say that this provider's immediate availability over the in-network 
providers was necessary to ensure your stability following relocation. The Plan denied your request. The Plan 
says the provider in this case has opted out of Medicare. The Plan also says payment cannot be made for 
services performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the office visits, care management services, and psychotherapy services provided from August 18, 2022, to 
October 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission based on the enrollee's condition and your strong recommendation that an 
LTACH is the most appropriate next level of care for this enrollee at this time. The Plan denied your request. 
The Plan says the requested LTACH admission 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 the enrollee appears to be improving but is still somewhat unstable and should only 
require short-term additional acute care services that can safely be provided at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH would not be clinically advantageous and completion of treatment at the 
current facility is recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESI). 
 
You asked the Plan to pre-approve epidural steroid injections. The Plan denied your request. The Plan says this 
is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that ESIs are covered for the indications established in the 
applicable LCD. 
 
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 epidural steroid injections. Our 
reviewer says that the requested ESIs are not medically reasonable and necessary. Our physician reviewer 
found that the documentation does not reveal objective evidence on a physical exam of lumbar radiculopathy. 
There are no dermatome, myotome, or reflex findings in the lower extremity in specific nerve root distribution 
that would necessitate an epidural steroid injection. There are no objective physical therapy documents 
indicating the dates, duration, and outcome of prior physical therapy. It is not clear that the enrollee has failed 
prior analgesic medications for this condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (ESI).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit (code 99285) provided on 
September 8, 2022. 
 
You asked the Plan to pay for the emergency department visit (code 99285). You say that the claim was billed 
with the appropriate code. The Plan denied your request. The Plan says that the Plan failed to provide a 
decision within the CMS timeframe. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule, a coding rule or a coding 
review to substantiate the denial. Therefore, we decided that the Plan has to pay for an emergency department 
visit (code 99285) provided on September 8, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) and supply allowance used with a therapeutic CGM device 
(K0553). 
 
You asked the Plan to pre-approve continuous glucose monitoring. You say that you do not like the needle 
which is your main cause of needing this item. The Plan denied your request. The Plan says the records do not 
show that the enrollee meets the medically necessary criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 continuous glucose monitoring. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records document a diagnosis of type 2 diabetes mellitus 
without complications. The records do not document that the enrollee is insulin treated with three or more daily 
administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump and the 
records do not document that the enrollee uses insulin.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous glucose monitoring have not been met. Therefore, we decided that 
the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic glucose 
continuous monitor system (K0554) and supply allowance used with a therapeutic CGM device (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) and electrical stimulator supplies, 2 lead, per month (A4595) provided September 4, 2022. 
 
You asked the Plan to pay for the TENS device and supplies. You say that according to the prescription, the 
prescribing physician recommends an extende3d lifetime use of equipment as they are diagnosed with chronic 
pain and compromised mobility without the option for surgical correction. The Plan denied your request. The 
Plan says evidence of misrepresentation. 
 
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 a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the enrollee and 
confirmed that the enrollee did not receive any supplies from the supplier. 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 transcutaneous electrical nerve stimulation (TENS) device (E0730) and electrical 
stimulator supplies, 2 lead, per month (A4595) provided September 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis Tab 5mg. 
 
You asked the Plan to pre-approve a prescription drug. You say that the enrollee has tried and failed other 
medications. The Plan denied your request. The Plan says the requested drug is a self-administered drug. The 
medication does not fall under Part B coverage. 
 
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 Eliquis Tab 5mg.
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 the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they do not meet the 
clinical requirements to be approved. 
 
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 that there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a lower level of 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on October 18, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that this claim is not a duplicate. You 
say the patient presented to the emergency department multiple times on the same date of service. The Plan 
denied your request. The Plan says that 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. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The enrollee presented to the emergency department 
multiple times on this date of service and the rendering provider is not the same. Based on this information, we 
decided that Medicare rules for coverage of the emergency department visit have been met. Therefore, we 
decided that the Plan has to pay for an emergency department visit provided on October 18, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says your 
insurance requires you receive non-emergency care from contracted, in-network providers. There are available 
in-network providers able to provide care for your condition. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the spinal canal 
and contents, cervical; without contrast material (72141). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary for 
the enrollee. 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has cervical neck pain with radiculopathy that is the same as he previously had prior 
to the injection. The record indicates that the enrollee had imaging performed one year ago that demonstrated 
extensive degenerative disease and prior fusion. The  record does not indicate the presence of red flag 
symptoms or signs. The record does not indicate the failure of conservative nonpharmacologic treatment. The 
requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's 
clinical condition at this time. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI), of the spinal canal and contents, cervical; without 
contrast material (72141).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on June 6, 2022. 
 
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 code 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 the technical report does indicate 
that an EEG was performed. However, this code is not supported as the enrollee was not in a coma or sleep. 
There are more appropriate codes to use in this clinical scenario. (e.g., 95812 and 95813). Therefore, the 
records do not support that CPT 95822: Electroencephalogram (EEG); recording in coma or sleep only were rendered. 
 
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 electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on June 
6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87502 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for procedure code 87502. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87502 is bundled into payment for code 87637. 
 
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 87502 
is a column II code to column I code 87637 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 87502 billed for date of service August 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 11, 2020. 
 
You asked the Plan to pay for the lab services. You say that it was not the provider's fault that this claim was 
not submitted on time. The Plan denied your request. The Plan says this claim was not filed timely. 
 
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 lab services was not filed until September 16, 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 lab services provided on September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria, and pertussis (Tdap) vaccine (90715), 
and administration (90471) provided on January 7, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that the injection had the incorrect billing code and 
was not paid. You also say that The Plan denied your request. The Plan says the services in this case are not 
covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and pertussis 
(Tdap) vaccine (90715), and administration (90471) provided on January 7, 2022.  
 
Benefits for the vaccine services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for muscle or tendon transfer, any type, upper arm or elbow, 
single provided to the enrollee on October 20, 2022. 
 
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 code 24301 is "Muscle or tendon transfer, any type, upper arm 
or elbow, single (excluding 24320-24331)." 
 
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 although the records do support 
that CPT 24301 was rendered in this case; it was essentially an inherent portion of the primary procedure, the 
reverse shoulder arthroplasty. 
 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 muscle or tendon transfer, any type, upper arm or elbow, single provided to the enrollee on 
October 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four units of CPT 11310 provided to the enrollee on April 
27, 2022. 
 
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 only one unit can be paid for. 
 
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 11310 is "Shaving of epidermal or dermal lesion, single 
lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less." 
 
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 the documentation submitted does 
not support CPT code 11310. The medical records in the case file consist of a pre-operative evaluation and 
consultation and photos of the patient's face. No operative report was submitted to support CPT code 11310. It cannot be verified that any units were performed. 
 
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 four units of CPT 11310 provided to the enrollee on April 27, 2022.