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

 
We decided that the Plan does not have [to pay for the acupuncture (97811, 98710), provided on November 24, 
2021. 
 
You asked the Plan [to pay for the acupuncture. You say that the service should be covered. The Plan denied 
your request. The Plan says you obtained this service through a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. These treatments may be provided by a physician in accordance with state requirements, or 
by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet 
certain licensure requirements.  
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you obtained this service through an acupuncturist 
instead of a physician. Therefore, we decided that the Plan does not have [to pay for the acupuncture (97811, 
98710), provided on November 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (38564) provided on November 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is inclusive to 
code 43632. 
 
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 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 use of code 38564 is 
not supported by the records provided. Our reviewer found that the operative report describes a 
lymphadenectomy and gastrectomy performed in the same area, therefore the lymphadenectomy would be 
included in the partial distal gastrectomy. 
 
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 the services (38564) provided on November 26, 2021.
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 nursing home is unable to 
accommodate the members condition. The Plan denied your request. The Plan says that your records do not 
show that you need continued treatments and care that can only be given in a hospital setting or that your 
condition will probably require an average 25 day length of stay in the LTACH. 
 
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. You were 
admitted for hypoxic and hypercapneic respiratory failure in the setting of COVID-19 pneumonia. The record 
indicates that you require ongoing acute care services before being able to transition to a lower level of care. 
You continue to receive acute care services, and these have not been denied. The medical record does not 
indicate that you require services that he is not currently receiving but that would be available at the LTACH 
facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 
services. 
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide (HHA) and home physical therapy 
(PT) services. 
 
You asked the Plan to pre-approve a HHA and PT services. You say that these services are crucial for you. You 
also say that you live alone, have a hard time, and are on a fixed income. The Plan denied your request. The 
Plan says you do not meet the Plan's criteria for home health services. 
 
  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 HHA and PT services. Our reviewer 
says that a HHA and PT services are not medically reasonable and necessary. Our physician reviewer found 
there is no up to date documentation that skilled therapy services are required to effectively provide treatment, 
care, and/or services in order to improve your level of function, or to establish/perform a maintenance program 
to maintain your level of function and/or prevent deterioration. Our reviewer found that there is no up to date 
documentation that the HHA services are reasonable and necessary for the treatment of your illness or injury by 
the skilled professional staff. Our physician reviewer also found that the most recent medical records available 
are from October 2021; no more up to date records are provided documenting a need for these services. 
 
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 HHA and PT services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home health aide (HHA) and home physical therapy (PT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on February 
16, 2022. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that authorizations are obtained 
by the surgeon and not the ancillary provider. You say that the claim should be reprocessed correctly for 
payment. The Plan denied your request. The Plan says CPT 00145 has been overturned and CPT code 99100 
remains denied as bundled services are not eligible for separate payment.  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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on February 16, 2022.
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. The Plan denied your request. The Plan says the enrollee does not 
need management by an intensive rehabilitation team. 
 
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 physician reviewer found 
that the enrollee was admitted to an acute hospital after a fall sustaining non-displaced left radius and 
trimalleolar fracture of left ankle. The enrollee is at a standby assist level for bed mobility and transfers, contact 
guard assist for ambulation, and supervision for activities of daily living.  The enrollee is medically stable with no new and acute medical problems and does not need PM&R physician 
supervision 3 times per week. At the current functional level, the enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day. An IRF admission is not medically necessary based on 
medical stability and lack of medical complexity, and lack of rehab nursing 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction service (92015) provided on February 11, 
2022. 
 You asked the Plan to pay for the eye refraction. You say that you needed your right eye checked for cataracts. 
The Plan denied your request. The Plan says this service was performed with a medical diagnosis. The Plan 
also says that your provider said you were seen for Drusen (degenerative) of macula, bilateral for the eye 
refraction. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eye refractions is performed during a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, this eye refraction was provided due to a diagnosis of 
Drusen (degenerative) of macula, bilateral, and not as part of a routine exam. Based on this information, we 
decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that 
the Plan does not have to pay for the eye refraction service (92015) provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve the requested services. You say that massage therapy is necessary for the 
ultimate success of other modalities. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid services provided on December 23, 2021. 
 
You asked the Plan to pay for routine hearing services. You say that you did not know you needed to see a 
specific provider for these services. The Plan denied your request. The Plan says hearing aids must be obtained 
from the specified vendor in order to qualify for coverage. The hearing aids in this case were purchased outside 
this specified network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are the specified models and purchased through the Plans specified vendor 
network.  
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans vendor network. 
Based on this information, we decided that the Plan's rules for coverage of routine hearing services have not 
been met. Therefore, we decided that the Plan does not have to pay for the hearing aid services provided on 
December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on November 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
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 83789 is a column II code to column I code G0480. 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 the mass spectrometry 
rendered on November 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on February 17, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on February 17, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SmartPill. 
 
You asked the Plan to pre-approve the SmartPill. The Plan denied your request. The Plan says the SmartPill 
is not indicated for gastroparesis. 
 
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 the SmartPill. Our reviewer says that 
the SmartPill is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that the record indicates that the enrollee has gastroparesis. There is insufficient literature to support the use of 
the requested service for the enrollee's specific clinical condition. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. 
 
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 SmartPill have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the SmartPill.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain (70551) 
provided on January 5, 2022. 
 
You asked the Plan to pay for the MRI. You say that the POS code used in this case is appropriate. The Plan 
denied your request. The Plan says the enrollee was registered inpatient on the date in question, and therefore 
the inpatient POS code should be used on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered inpatient, the 
inpatient POS code should be reported regardless of where the face-to-face takes place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MRI have not been met. Specifically, this claim was billed with the On-Campus Outpatient 
Hospital POS code (22). The records indicate that the enrollee was inpatient status on the date in question. 
Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the 
brain (70551) provided on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 10, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(92250) provided on February 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam with photos provided OON. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the requested service is not covered because 
it was provided OON. 
 
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 the fundus photography with interpretation and 
report (92250) provided on February 16, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each 
additional 15 minutes (97811) provided October 18, 2021. 
 You asked the Plan to pay for the acupuncture services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the services were rendered by a non-
covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were rendered by a licensed 
acupuncturist, not a physician. Acupuncture treatments must be provided by a physician practicing within the 
scope of their liscense.  Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 
minutes (97810) acupuncture, each additional 15 minutes (97811) provided October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiopulmonary resuscitation services coded 92950 and 
the cardioversion services coded 92960 provided on December 17, 2021. 
 You asked the Plan to pay for the cardiopulmonary resuscitation services and the cardioversion services. You 
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services billed are not separately payable. 
 
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 92950 
is a column II code to column I code 92960 Also, Code 92960 is a column II code to column I code 99292. 
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 the 
cardiopulmonary resuscitation services coded 92950 and the cardioversion services coded 92960 provided on 
December 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the member has tried conservative treatments 
that have not worked. The Plan denied your request. The Plan says that there is little evidence in the medical 
literature to suggest that this is an appropriate procedure for the enrollee's back pain. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.