Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve TTE. 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 TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are not apparent significant changes in the enrollee's clinical condition. Documentation 
does not support repeating a TTE with no intervening change in clinical status of physical findings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transthoracic echocardiography (TTE) (93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of admission. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information we have about the 
enrollee's condition they do not meet all the requirements. 
 
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 clinical documentation shows that the enrollee has functional impairments 
however the enrollee is medically stable from an outpatient level.  There are no complex functional deficits specified, thus the complexity of the enrollee's documented nursing, 
medical, and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service July 1, 2022. 
 You asked the Plan to pay for the billed services. You say that the service is not bundled. The Plan denied your 
request. The Plan says the code is bundled as part of the global surgical fee. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99291 is not supported. The claim was not billed with a modifier suitable for critical 
care visits during the global surgery period. 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 code 99291 billed for date of service July 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the acute inpatient rehabilitation is medically 
necessary. The Plan denied your request. The Plan says criteria for admission to the acute inpatient 
rehabilitation setting have not been met. 
 
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 requires pain management and mobility as tolerated. The enrollee does 
not require intensive rehabilitation services nor does he have the capacity to participate in intensive therapy. Pain as well as the enrollee's endurance limit his capacity to improve function and his capability to participate 
in intensive therapy. He does not require frequent physiatry oversight as he has routine uncomplicated 
rehabilitation needs. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 26, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on October 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Medicare Part B prescription drugs 
provided on August 25, 2022. 
 
You asked the Plan to waive the copayment for Medicare Part B prescription drugs. You say that you disagree 
with the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the prescription drugs $908.50. You are being asked to pay $181.70 ($908.50 x 20% = $181.70). 
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. Therefore, we decided that the Plan 
does not have to waive the copayment for Medicare Part B prescription drugs provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Covid 19 Monoclonal Antibody treatment provided on 
December 18, 2021. 
 
You asked the Plan to pay for the Covid 19 Monoclonal Antibody treatment. You say that the service should be 
covered. The Plan denied your request. The Plan says this provider does not participate in 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 Covid 19 Monoclonal Antibody 
treatment provided on December 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of subcutaneous cardiac rhythm monitor 
(33285). 
 
You asked the Plan to pre-approve insertion of subcutaneous cardiac 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 of subcutaneous cardiac 
rhythm monitor. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the old ILR showed no evidence of atrial fibrillation, 
nor is there a history of syncope or any other indication for ILR implant. As such, based on current guidelines 
and the documentation provided, there is insufficient clinical evidence to support the medical appropriateness 
and necessity of this request. 
 
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 of subcutaneous cardiac rhythm monitor have not been met. Therefore, 
we decided that the Plan does not have to pre-approve insertion of subcutaneous cardiac rhythm monitor 
(33285).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (77525). 
 
You asked the Plan to pre-approve proton beam therapy. 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 proton beam therapy. 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 compelling data to suggest that proton therapy is superior to or more 
beneficial than intensity-modulated radiation therapy or image-guided radiation therapy. The generally 
accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not 
routinely offer it to enrollees. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77525).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheterization and ventriculography (93458). 
 
You asked the Plan to pre-approve catheterization and ventriculography. 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 catheterization and ventriculography. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is described as having stable, atypical angina, with stress 
test eliciting no chest pain and showing small to medium area of ischemia. Medical therapy has not been 
maximized. Guidelines do not support a need for cardiac catheterization in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of catheterization and ventriculography have not been met. Therefore, we decided 
that the Plan does not have to pre-approve catheterization and ventriculography (93458).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628) and thermal 
destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, 
lumbar or sacral (List separately in addition to code for primary procedure) (64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are filing an appeal for the 
wrongful denial for Intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept 
procedure. The Plan denied your request. The Plan says there are not enough studies that show that the 
Intracept procedure is safe and effective. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 
vertebral bodies, lumbar or sacral (64628) and thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to 
code for primary procedure) (64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation services (G0283 x 4) provided from 
June 17, 2022, through June 29, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not covered by the 
Plan or by Medicare. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulation services (G0283 x 4) provided from June 17, 
2022, through June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Lumbar-sacral orthosis (LSO) (L0650), provided on 
August 19, 2022. 
 
You asked the Plan to pay for the LSO. You say that the item was medically necessary. The Plan denied your 
request. The Plan says this item is not documented in patients medical records. 
 
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 physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The medical records submitted do not indicate a back brace was  
ordered or discussed. 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 Lumbar-sacral 
orthosis (LSO) (L0650), provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the physical exam (G0402), 
electrocardiogram (93000), and advance care planning (99497), provided on October 21, 2021. 
 
You asked the Plan to waive the deductible for the preventative services. You say that the service should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to an out-of-network Welcome to 
Medicare" preventive visit.  
 
The item or service you asked the Plan to waive the deductible for falls within the Welcome to Medicare" 
preventive visit benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $500 deductible which applies to a out-of-network Welcome to Medicare" preventive visit. This 
cost sharing is a contractual obligation that had not been met at the time the preventative services was received 
on October 21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the physical 
exam (G0402), electrocardiogram (93000), and advance care planning (99497), provided on October 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee still requires focused therapy that only 
skilled nursing rehabilitation can provide in order to continue to improve. The Plan denied your request. The 
Plan says the SNF care is not medically necessary, and the enrollee's needs can be met at a lower level of care 
such as a long-term care facility. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0425 billed for date of service August 5, 
2021. 
 
You asked the Plan to pay for procedure code G0425. The Plan denied your request. The Plan says payment for 
code G0425 is bundled into payment for code 99308. 
 
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 G0425 is a column II code to column I code 99308 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 G0425 
billed for date of service August 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you would like reconsideration because the 
service is medically necessary. The Plan denied your request. The Plan says an additional 10 physical therapy 
visits is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that your head injury does not meet coverage criteria for the requested 
additional physical therapy visits. Additional visits are not medically necessary for a seven-month-old injury. 
However, it is reasonable for reassessment of their function in 3 months- time after home exercise program was 
provided and implemented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional physical therapy visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BLS routine disposable supplies (A0382 x2) provided on 
June 18, 2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that this was an emergency transport, so the 
you should not be billed. The Plan denied your request. The Plan says BLS routine disposable supplies are not 
covered by Medicare. 
  The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for BLS routine disposable supplies (A0382 x2) provided on 
June 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 81479, 81407, G0452 provided on July 11, 2022. 
 
You asked the Plan to pay for codes 81479, 81407, G0452. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 85060, 81305, and 81347 are not supported in the medical record. Specifically, the 
documentation shows that FISH and flow ytometry procedures were completed. There are more specific codes 
to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage 
of codes 81479, 81407, G0452 have not been met. Therefore, we decided that the Plan does not have to pay for 
codes 81479, 81407, G0452 provided on July 11, 2022.