Persius/hicric huggingface dataset:
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 doctors changed your medications recently, and 
you are experiencing side effects from these medication changes. You also say that you feel you have gotten 
weaker, your feet swell, and you are weak where you cannot walk. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomographic angiography (CTA) of the chest with 
contrast (71275) provided on November 8, 2021. 
 
You asked the Plan to pay for the CTA. You say that this claim should be paid. The Plan denied your request. 
The Plan says this is a duplicate of a claim which has already been paid. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that claims or claim lines which have been determined to be a duplicate with respect to certain 
elements are denied. 
 
We find that CPT code 71275 is not supported in the medical record. Specifically, the documentation 
forwarded to us for review includes a copy of another claim billed by this provider for this same service which 
was performed on this enrollee on the same date. This documentation shows this claim has been paid. The 
medical records provided do not indicate that this same CTA was performed twice on the date in question. 
Based on this information, we decided that Medicare rules for coverage of the CTA have not been met. 
Therefore, we decided that the Plan does not have to pay for computed tomographic angiography (CTA) of the 
chest with contrast (71275) provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on February 4, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2781) provided on February 21, 
2022. 
 You asked the Plan to pay for the eyeglasses. You say that your glasses broke, and you needed a replacement 
pair. The Plan denied your request. The Plan says you previously received a pair of routine eyeglasses on 
January 26, 2021, which were covered by the Plan at that time. Your benefit covers one pair of eyeglasses 
every two years. 
 
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 once every two years. 
 
We looked at the file and the Plan's rules. The documentation supports that the eyeglasses are requested in a 
frequency that is not covered by your vision benefit. Based on this information, we decided that the Plan's rules 
for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for 
the eyeglasses (V2020, V2781) provided on February 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) occupational therapy (OT) visits to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve 12 OT visits. You say that while verifying eligibility and benefits for the 
enrollee, you were told that you were not in network with the Plan. You were also told that if you submitted an 
authorization that you would be considered in-network. The Plan denied your request. The Plan says there are 
in-network providers available for this service. 
 
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 
twelve (12) occupational therapy (OT) visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otolaryngologist visit with a network tertiary provider. 
 
You asked the Plan to pre-approve Otolaryngologist visit with a network tertiary provider. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services can be provided by a non-tertiary provider. 
 
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 Otolaryngologist visit with a network 
tertiary provider. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found you have a diagnosis of Cochlear otosclerosis, 
bilateral. You were seen by a physician for an annual physical on January 31, 2022 where no ear, nose, and 
throat (ENT) symptoms were reported. The documentation does not support that you have a diagnosis or 
condition that would be best evaluated and treated only by a tertiary provider. Therefore, your care needs can 
reasonably be met by a non-tertiary provider. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Otolaryngologist visit with a network tertiary provider have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Otolaryngologist visit with a network tertiary 
provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services provided on October 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that the records support the service rendered. The 
Plan denied your request. The Plan says that the claim was billed with an inappropriate place of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan appears to contradict themselves. In their rationale for denial, they 
state the enrollee was an outpatient during the dates of service October 13-14, 2021. They then go on to say 
that the documentation does not indicate whether the enrollee was registered as an inpatient or outpatient. The 
claim information shows that the enrollee received services in the emergency department and was then 
admitted as an inpatient. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the evaluation and management services provided on October 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on February 
4, 2022. 
 
You asked the Plan to pay for the blood smear 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 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. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this code was billed with 
place of service 22 (outpatient hospital). This is an inappropriate place of service for this code. Therefore, this 
code is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
blood smear services have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
February 4, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the needle electromyography, other than paraspinal (95870) provided to 
the enrollee on July 21, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that that evidenced based research articles report that there is not enough 
scientific evidence to conclude that intraoperative monitoring reduces surgical risks and improves outcomes in 
patients. 
 
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 pay for these services. Our reviewer says that these 
services were medically reasonable and necessary for the enrollee. The member underwent a procedure during 
which there was a potential risk to the spinal cord (as the levels worked on were before the end of the cord). In 
such surgeries the provision/use of intraoperative neuromonitoring is otherwise considered to be within the 
generally accepted standard of care. Our physician reviewer found that the enrollee's condition meets criteria 
for coverage of 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.  
 
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 pay for these services. Therefore, we decided that the Plan has to 
pay for the needle electromyography, other than paraspinal (95870) provided to the enrollee on July 21, 2021, 
by an out-of-network (OON) provider.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the chest. 
 
You asked the Plan to pre-approve a CT of the chest. The Plan denied your request. The Plan says medical 
necessity has not been met. 
 
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 a CT of the chest. Our reviewer says 
that a CT of the chest is not reasonable and necessary. Our physician reviewer found is important to understand 
that a routine chest x-ray is a poor screening tool for rib fracture. Our reviewer found that there is no 
explanation of what therapeutic difference the detection of another rib fracture would be. Our physician 
reviewer also found that the medical necessity of a CT of the chest at this point has not been established. 
 
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 CT of the chest have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on February 1, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram provided on December 18, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 electrocardiogram provided on December 18, 
2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on December 30, 
2021, and December 31, 2021. 
 
You asked the Plan to pay for critical care. You say that these services were necessary and have been reported 
correctly. The Plan denied your request. The Plan says these services are not supported as 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing 
these services is not supported in the record. Based on this information, we decided that Medicare rules for 
coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for 
critical care, first hour (99291) provided on December 30, 2021, and December 31, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retroperitoneal ultrasound (76770) provided on January 
28, 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 this is a duplicate of another claim which has already 
been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that a claim or claim lines that have been determined to be an exact duplicate with respect to 
certain elements are rejected. 
 We find that CPT code 76770 is not supported in the medical record. Specifically, this claim appears to be a 
duplicate. The documentation provided for review includes a copy of another claim for this same service 
performed by the same provider for the same enrollee on the same date. This claim has been paid by the Plan 
and has not been denied. The medical records provided for review also show no indication that the enrollee 
received this service twice on the date in question. Based on this information, we decided that Medicare rules 
for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for 
the retroperitoneal ultrasound (76770) provided on January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the pelvis without contrast 
material (72192) provided on January 14, 2022. 
 
You asked the Plan to pay for CT of the pelvis. 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 74176 and 72192. 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 72192 
is a column II code to column I code 74176. 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 computed tomography (CT) of the pelvis without contrast 
material (72192) provided on January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the conditions listed for denial have been 
addressed or are improving. The Plan denied your request. The Plan says based on Medicare guidelines, the 
Long-Term Acute Care Hospital (LTACH) services you 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. Our physician reviewer also found that the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 
 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.