Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services (64910) provided on October 1, 2021. 
 
You asked the Plan to pay for the surgical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the surgical services by a contract provider. The file does not show that the Plan 
provided notice that the surgical services would not be covered. Under Medicare rules, this means the surgical 
services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the surgical 
services (64910) provided on October 1, 2021.  
 
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 you need IRF care. The Plan denied your request. 
The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for 
approval. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex 
nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on August 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve promethazine suppository. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has tried and failed other 
medications but had good results with promethazine. The Plan denied your request. The Plan says the denial of 
authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not 
administer the enrollee's Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve promethazine suppository.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or outpatient visit (99203) provided on May 10, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office or outpatient visit. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says prior authorization is required and was 
not obtained. 
 
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 office or outpatient visit (99203) provided on 
May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an Off-Campus Outpatient Hospital setting. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the patient must be monitored with daily 
labs. The Plan denied your request. The Plan says the LTACH services requested do not meet the requirements 
for approval. 
 
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 that the medical record does not indicate that the enrollee requires services that she is 
not currently receiving but would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied, and the requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided June 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 G0482 is not supported in the medical record. Specifically, the place of service on the 
claim form (81, lab) does not match the place of service detailed in the records (11, office setting). Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (G0482) provided June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy (36475 and 36476). 
 
You asked the Plan to pre-approve endovenous ablation therapy (36475 and 36476). You say that the patient 
has clearly documentation venous disease with symptoms of pain, chronic fatigue and chronic edema. You say 
that the patient has been treated conservatively with no significant improvement and the patient clearly 
qualifies medically. The Plan denied your request. The Plan says ablation of the perforator veins in not a 
covered benefit. 
 
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 endovenous ablation therapy (36475 
and 36476). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that this procedure is only approved for treatment of the 
greater or lesser saphenous veins. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy (36475 and 36476) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve endovenous ablation therapy (36475 and 36476).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you believe that the hospital is not 
equipped to handle your condition and you will continue to deteriorate if you stay there. The Plan denied your 
request. The Plan says you do not meet Medicare criteria for coverage. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower back 
spine for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the annual wellness visit stated that there are no current problems or complaints. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found detailed documentation 
is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative 
care measures. Additionally, there are no red flags indicated on exam as severe and/or progressive neurological 
abnormalities has not been documented. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the request for magnetic resonance imaging (MRI) of the lower back spine is not medically reasonable or 
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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lower back spine for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for a spinal injection (77003) 
provided on August 10, 2021. 
 
You asked the Plan to pay for the fluoroscopic guidance. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code 77003 has not been billed with 
an appropriate primary procedure code. 
 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 the 
fluoroscopic guidance is an add-on code and has not been billed with an appropriate primary procedure code. 
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 fluoroscopic guidance for a spinal injection (77003) provided on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network 
care. 
 
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 laboratory services provided on October 1, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker with an enclosed frame (E0144) provided on 
August 4, 2021. 
 
You asked the Plan to pay for a walker with an enclosed frame. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that if an enclosed frame walker is provided it will be 
denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for 
coverage of a walker with an enclosed frame have not been met. Therefore, we decided that the Plan does not 
have to pay for a walker with an enclosed frame (E0144) provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires (A4557) and additional supplies and materials 
(99072) provided on May 6, 2021. 
 
You asked the Plan to pay for the lead wires (A4557) and additional supplies and materials (99072). You say 
that you are a non-contracted provider, and the Plan is required to pay contracted rates or 125% of local 
coverage. You say that the bill should be reviewed, and appropriate fee should be issued. The Plan denied your 
request. The Plan says bundled services are not eligible for separate reimbursement. 
 
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 A4557 is lead wires, (e.g., apnea monitor), per pair. The 
CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and 
above those usually included in an office visit or other non-facility service(s), when performed during a Public 
Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. 
 
We find that CPT code A4557 is not supported in the medical record. Specifically, CPT code A4557 has a 
status indicator of P and CPT code 99072 has a status indicator of B. This means that CPT codes A4557 and 
99072 are considered bundled and not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the lead wires (A4557) and additional supplies and materials (99072) have not been met. 
Therefore, we decided that the Plan does not have to pay for the lead wires (A4557) and additional supplies and 
materials (99072) provided on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on 
July 7, 2021, during a facility stay. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says this equipment was provided during a facility stay and is not paid separately.  
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier 
other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. This equipment was used during and after a surgical procedure by the facility.  Payment for this service would have been included under the facility claim. Payment to you for this service is 
the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a 
pneumatic compression device provided to the enrollee on July 7, 2021, during a facility stay.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 29827) provided to the 
enrollee on May 13, 2021. 
 
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 code 29827 has an MUE value of 1 but billed 2 units for which units are exceeded. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29827 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 surgical services 
(procedure code 29827) provided to the enrollee on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 8, 2021. 
 
You asked the Plan to pay for the testing services. You say that the referring physician is a contract provider. 
The Plan denied your request. The Plan says only medically necessary services are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. We find that the drug testing is not supported in the medical record. 
Specifically, the records show that drug monitoring was ordered. The records do not show that the testing was 
ordered due to side effects, clinical assessment, or a change in behavioral patterns. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the drug testing services provided on July 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for magnetic resonance 
imaging (MRI). 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is an available network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for magnetic resonance imaging (MRI).