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

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service July 20, 
2022. 
 
You asked the Plan to pay for the billed service. You say that the enrollee was examined and counseled before 
the procedure was performed. The Plan denied your request. The Plan says the payment for surgery includes 
same day visits. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We find that code 99213 was billed on the same claim as code 10060, which is a minor procedure. Visits by the 
same physician on the same day as a minor surgery are included in the payment for the procedure. The medical 
records do not show that the evaluation and management services were significant and separately identifiable 
from the procedure performed. Based on this information, we decided that Medicare rules for coverage of the 
billed service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99213 billed for date of service July 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on June 3, 2022. 
 
You asked the Plan to pay for the electrocardiogram. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not supported by the records provided. 
 
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 93010 is Electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
 
 
 
 
 
 
 We find that CPT code 93010 is not supported in the medical record. Specifically, the record did not include a 
separate physician report or interpretation for the electrocardiogram. Based on this information, we decided 
that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the 
Plan does not have to pay for an electrocardiogram (93010) provided on June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on August 1, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services are considered medically 
necessary. The Plan denied your request. The Plan says that experimental or investigational services are 
excluded from coverage. 
 
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. 
 
We looked at the file and the rules. Medicare does cover electrical stimulation as a benefit. The medical records 
show that electrical stimulation is part of the enrollees treatment plan. The Plan has not provided Medicare 
ruling or any other rationale to show that the services are experimental in nature. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request.  Therefore, we decided that the Plan has to pay for the electrical stimulator supplies provided on 
August 1, 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 enrollee's functional status post hip fracture repair does not require intensive 
therapy to restore function. The enrollee does not require frequent physiatry oversight. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous rhythm monitor (33285). 
 
You asked the Plan to pre-approve insertion, subcutaneous rhythm monitor. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is 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 pre-approve insertion, subcutaneous rhythm 
monitor. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no documentation provided to suggest a history of 
unexplained recurrent syncope, cryptogenic stroke or any other apparent indication for an implantable cardiac 
monitor. The enrollee has a history of paroxysmal atrial fibrillation. There is insufficient documentation to 
support the medical necessity for insertion of an implantable cardiac monitor in this patients clinical 
management. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion, subcutaneous rhythm monitor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion, subcutaneous rhythm monitor (33285).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor (CGM) on July 5, 2022. 
 
You asked the Plan to pay for a continuous glucose monitor (CGM). You say that the services requested are 
medically necessary. The Plan denied your request. The Plan says that you do not meet the criteria for 
approval. 
 
The Plan must follow 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 pay for a continuous glucose monitor (CGM). Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee meets the 
criteria for approval. 
 
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 continuous glucose monitor (CGM) have been met. Therefore, we decided 
that the Plan has to pay for a continuous glucose monitor (CGM) on July 5, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code A0425. You say that these services are supported as billed. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed per line for 
this service. 
 
The Plan must follow Medicare rules. Medicare rules say that for codes with an MAI of 1, each line of a claim 
with that HCPCS/CPT code will be separately adjudicated against the MUE value for that code. A single line 
may not exceed the MUE for that code, but additional lines for additional units may be reported with an appropriate modifier. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 263.1 units of 
this code on one line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A0425 billed for date of service July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item is not primarily medical in nature. 
 
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 power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MediButler stocking application device. 
 
You asked the Plan to pre-approve stocking application device. You say that this is medically necessary for 
you. The Plan denied your request. The Plan says this device is not primarily medical in nature and is not 
covered. 
 
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 MediButler stocking application device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on September 14, 2022. 
 
You asked the Plan to pay for the drug testing. You say that claims for COVID-19 testing should be paid. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on September 14, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF is not medically 
necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollees nursing medical and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted to the 
hospital on January 24, 2023, for chest pain and required coronary artery bypass grafting and left atrial 
appendage closure on January 26, 2023. The enrollee is currently tolerating medications, requiring sternal 
precautions, and not requiring supplemental oxygen. However, given the enrollee's comorbidities and recently 
undergoing cardiac surgery, the enrollee would benefit from the intensity of rehabilitation physician oversight 
provided in the acute inpatient rehabilitation setting. The enrollee's medical and rehabilitation needs do require 
the intensive interdisciplinary approach provided on acute inpatient rehabilitation. The enrollee has had a 
decline from his baseline level of function and would benefit from the intensity of therapies provided on acute 
inpatient rehabilitation. The enrollee can tolerate therapy three hours per day, five days per week. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) provided June 21, 
2022. 
 
You asked the Plan to pay for the outpatient services. You say that enclosed is the requested supporting 
documentation so that this claim can be reprocessed for payment. The Plan denied your request. The Plan says 
the rendering provider is a Registered Nurse and is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment 
(G2067) provided June 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that 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 the enrollee requires 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 pre-approve a myocardial perfusion imaging (MPI), single photon 
emission computed tomography (SPECT) (78452). 
 
You asked the Plan to pre-approve a SPECT scan. You say that your doctor noticed an issue with your 
electrocardiogram (EKG) and breathing. The Plan denied your request. The Plan says results of an 
electrocardiogram are needed to show that this study is needed. The Plan also says the records do not show 
results of a prior picture study, such as an x-ray or ultrasound, that support further imaging. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary for patients experiencing new, recurrent, or worsening cardiac symptoms, 
including otherwise unexplained angina equivalent symptoms, and a new or previously unrecognized 
uninterpretable electrocardiogram (ECG). 
 
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 SPECT scan. Our physician reviewer 
found there is no documentation that the ECG shows an uninterpretable pattern. There is no evidence provided 
that would support the need for radionuclide stress testing at this time. Our reviewer also found that there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing in your 
clinical management. 
 
 
 
 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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a myocardial perfusion imaging (MPI), single photon emission computed tomography 
(SPECT) (78452).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81410 and 81411 billed for services 
provided on August 28, 2022.  
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the testing is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Billed codes 81410 and 81411 are unlikely to impact therapeutic 
decision making. Furthermore, the gene panel was not billed with a single code as required. 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 procedure codes 81410 and 81411 billed for services 
provided on August 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are necessary for the enrollee to regain 
strength in the legs and feet as well as to gain more balance. The Plan denied your request. The Plan says the 
requested IRF services are not medically necessary. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program.  While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 an IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the Yutiq injection provided on July 01, 
2022. 
 
You asked the Plan to reduce the coinsurance for the Yutiq injection. You say that you should only have a $295 
copayment. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the Yutiq injection. This item/service falls within the 
Medicare Part B prescription drugs 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. The Medicare allowed amount for the injection is $9,329.94, and the 20% 
coinsurance is $1,865.99. Therefore, we decided that the Plan does not have to reduce the coinsurance for the 
Yutiq injection provided on July 01, 2022.