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

 
We decided that the Plan has to pay for thoracentesis, needle or catheter, aspiration of the pleural space; 
without imaging guidance provided to the enrollee on August 11, 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 that 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 32554 is "Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance." 
 
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 supported by the medical records. Our reviewer found that thoracentesis was performed by the 
provider on 8/11/22 as documented in the medical records provided. This was done by catheter over needle 
under ultrasound guidance. 700ml of fluid was removed. This corresponds to CPT 32554 and should be paid. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance provided to the 
enrollee on August 11, 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation shows that the enrollee has had medical status change and requires 
skilled nursing assessment. Clinical documentation shows that the enrollee has new functional impairments and 
evaluating therapists recommend daily skilled therapy. From a practical standpoint, the enrollee requires daily 
skilled services in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
   
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cochlear device implantation provided 
on October 21, 2021. 
 
You asked the Plan to waive the coinsurance for a cochlear device implantation. You say that this was the 
closest provider that could perform the surgery. 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 30% 
coinsurance for outpatient surgery. 
 
You have been asked to pay 30% coinsurance for a cochlear device implantation. This item/service falls within 
the outpatient surgery 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 coinsurance for a cochlear 
device implantation provided on October 21, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scans of the chest (71260), the neck 
(70491) and the abdomen and pelvis (74177). 
 
You asked the Plan to pre-approve CT scans. You say that the requested services are a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scans. Our reviewer says that the 
requested CT scans are medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has clinical evidence of delayed metastatic disease, which required hemipelvectomy in 2021 due to 
bone destruction by distant metastasis. The enrollee has known bilateral pulmonary nodules, which have been 
stable. The enrollee presents with numbness, burning and tingling in the upper extremities. The enrollee's last 
CT scan of the chest, abdomen and pelvis was October 13, 2022. It is very reasonable to offer surveillance 
every 3 months in the enrollee who has developed distant metastases requiring radical hemipelvectomy as 
recently as 2021. The requested CT scans of the chest and of the abdomen and pelvis is very reasonable as a 
surveillance tool. The CT scan of the neck makes sense due to the history of distant metastatic disease and 
recent onset of bilateral upper extremity symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scans have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scans of the chest (71260), the neck (70491) and the abdomen and pelvis (74177).  
 
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 pay for office visit provided on August 29, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. 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 office visit provided on 
August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the periodic oral evaluation (D0120). We decided that the Plan does not 
have to pay for the cleaning (D1110) and the fluoride treatment (D1206).  
 You asked the Plan to pay for the periodic oral evaluation (D0120), the cleaning (D1110) and the fluoride 
treatment (D1206) provided on September 6, 2022. You say that you had oral cancer which resulted in an 
extremely dry mouth and a jaw infection.  The Plan says that the fluoride treatment (D1206) is not a covered 
benefit and the frequency limitations for the periodic oral evaluation (D0120) and the cleaning (D1110) have 
been met. 
 
We decided that the Plan has to pay for the periodic oral evaluation (D0120).  
 
The record shows the Plan paid for a periodic oral evaluation on February 16, 2022. This is more than six 
months from the periodic oral evaluation on the date of service at issue. Therefore, we decided that the Plan has 
to pay for the periodic oral evaluation on September 6, 2022.  
 
We also decided that the Plan does not have to pay for the cleaning (D1110) and the fluoride treatment 
(D1206). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the fluoride treatment (D1206) is not 
among those covered under this benefit. Though the Plan offers a dental benefit in excess of Medicare 
coverage, certain limitations apply. The record shows your benefit for the cleaning (D1110) was exhausted on 
date of service May 18, 2022. Therefore, we decided that the Plan does not have to pay for the cleaning 
(D1110) and the fluoride treatment (D1206). 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the services requested are 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 medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 10, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 is a column II code to column I code 70496. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 
billed for date of service May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept) procedure (64628, 64629 x 2). 
 
You asked the Plan to pre-approve Intracept procedure. You say that the requested procedure is medically 
necessary. You also say that it is supported by strong science. The Plan denied your request. The Plan says the 
requested procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is considered experimental. Therefore, the reviewer found 
that this procedure is not medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept) procedure (64628, 
64629 x 2).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve injections. You say that the injections are medically necessary. You also say 
that if the requested injections are successful, a radiofrequency ablation (RFA) will be performed as the next 
step. The Plan denied your request. The Plan says that the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients. 
 
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 injections. Our reviewer says that the 
requested injections are medically necessary. Our physician reviewer found the provided documentation 
supports that the pain has been present for at least three months with a documented failure to respond to 
conservative treatments. The reviewer found that there is no untreated radiculopathy or neurogenic 
claudication. The reviewer also found that there is no non-facet pathology shown on imaging that could explain 
the source of the enrollees pain. Therefore, the reviewer found that the injections are medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have been met. Therefore, we decided that the Plan has to pre-
approve facet joint injections (64493, 64494).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nasal/sinus endoscopy, surgical with ethmoidectomy; 
partial (anterior) provided to the enrollee on May 16, 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 CPT 31254 is not a payable code for this claim. 
 
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 31254 is "Nasal/sinus endoscopy, surgical with 
ethmoidectomy; partial (anterior)." 
 
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 medical records provided, 
particularly, the EOB indicates 31254 was billed with a 50 modifier as well as CPT 31267.  In this case, an 
additional modifier is required in order for CPT 31254 50 to be considered for reimbursement. Although there 
is a letter from the billing manager stating 31254 was billed with a 50 modifier and a 59 modifier, it is not evident on the Explanation of Benefits, therefore, this cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) provided to the 
enrollee on May 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services 
(90792) provided on August 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation with medical services. You say that the 
enrollee was referred for services. The Plan denied your request. The Plan says there was no prior authorization 
for the services. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical 
services (90792) provided on August 24, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gene panel testing provided on May 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records prove medical necessity. The 
Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the panel testing 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 gene panel testing provided on May 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of CPT 93971 provided to the enrollee on 
July 19, 2022. 
 
You asked the Plan to pay for the additional unit. You say that this should be paid for. The Plan denied your 
request. The Plan says the documentation only supports one unit, which was approved. 
 
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 93971 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study." 
 
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 additional unit. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that the documentation does 
not support coverage of a second instance of CPT code 93971. There is no documentation suggesting that an 
additional extremity venous study was required or performed.  There is no evidence that a unique report was 
created for a second instance of code 93971.  
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 additional unit have not been met. Therefore, we decided that the Plan does 
not have to pay for an additional unit of CPT 93971 provided to the enrollee on July 19, 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 admission to IRF care is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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.