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

 
We decided that the Plan has to pre-approve radiopharmaceutical localization of tumor, inflammatory process 
or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when 
performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan 
for anatomical review, localization and determination/detection of pathology, single area (eg, head, neck, chest, 
pelvis), single day imaging. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary to confirm a diagnosis 
of Parkinson's disease or to rule out Parkison's disease as a possibility. The Plan denied your request. The Plan 
says that this does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the request in this case is not for a positron emission tomography/computed tomography (PET/CT) 
scan.  Rather the requested dopamine transporter scan (DaT) scan with SPECT is a test targeting dopamine 
activity in the striatum of the brain and in this particular case will help the neurologist differentiate what are 
possibly essential tremors from those associated with Parkinson's Disease.  This differentiation is important in 
order to facilitate treatment if Parkinson's Disease is responsible for the tremors. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve radiopharmaceutical localization of tumor, inflammatory process or distribution of 
radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic 
(SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, single area (eg, head, neck, chest, pelvis), single day 
imaging.  
 
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 pre-approve a Minuteman device. 
 
You asked the Plan to pre-approve a Minuteman device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a Minuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Minuteman device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laboratory service provided on June 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory service. You say that we depend upon the hospital staff to verify 
eligibility and to obtain the proper authorization from the beneficiary's Plan. The Plan denied your request. The 
Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an out-
of-network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 laboratory service provided on June 22, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 6, 2021, to 
December 10, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
documentation supports the inpatient care as originally billed. The Plan denied your request. The Plan says 
there is no support the billed principal diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, N17.9, defined as acute 
kidney injury, unspecified. 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 the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
billed principal diagnosis code. Our physician reviewer found that the enrollee was a then, 62-year-old male 
who presented to the emergency department for evaluation of abnormal lab values. The enrollee had a past 
medical history of hypertension, diabetes mellitus, and benign prostatic hyperplasia. The enrollee was 
diagnosed with acute renal failure and urinary tract infection and was admitted for further care. Initial 
laboratory study results included a blood urea nitrogen of 65 mg/dL, creatinine 3.8 mg/dL, and estimated 
glomerular filtration rate 15. The patient had a history of chronic kidney disease with a baseline Creatinine of 
1.1. Discharge summary noted the patient had acute renal failure likely related to obstructive nephropathy as he 
did have urinary retention. In this case the patient had a clearly documented obstructive nephropathy with 
urinary retention which increased the creatinine. The review has determined that the documentation did not 
support the payment of inpatient hospital services as billed with the principal diagnosis code N17.9, defined as 
acute kidney injury, unspecified.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 6, 2021, to December 10, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that due to a short time period you were unable to get the 
authorization for this date of service. You are appealing with supporting records and requesting a review and 
reprocessing of this claim. The Plan denied your request. The Plan says the enrollee must receive care from a 
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 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 an office visit provided on August 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on June 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you do not personally see patients and are dependent 
on receiving patient information from the ordering provider. The Plan denied your request. The Plan says the 
enrollee must receive care from a 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 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 drug testing provided on June 29, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service July 17, 
2022. 
 
You asked the Plan to pay for procedure code 71250. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 71250 is bundled into payment for code 71275.  
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 71250 
is a column II code to column I code 71275. 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 71250 billed for date of service July 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interlaminar/interspinous process device. 
 
You asked the Plan to pre-approve the interlaminar/interspinous process device. You say that this device is 
medically necessary. The Plan denied your request. The Plan says the requested device is considered 
experimental/investigational. 
 
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 interlaminar/interspinous process 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested interlaminar device is experimental. More 
research is needed before coverage can be approved. 
 
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 interlaminar/interspinous process device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the interlaminar/interspinous process device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing for 22 or more drug classes 
(G0483) provided July 26, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you disagree with the finding for the 
requested refunds. Your clinics complete presumptive urine drug testing for medical necessity of your patients 
who are prescribed opioids as part of your clinical regulations. The Plan denied your request. The Plan says the 
requested number of definitive drug classes are 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the diagnosis is medication management of long term (current) drug therapy. The 
medical record sent by the provider shows presumptive screening test results which are partially inconsistent 
with prescription medications, or history and expected results. Definitive confirmation testing was medically 
necessary for only 3 drug classes: Opiates; Oxycodone; and Cannabinoids, natural. The review has determined 
that the medical records provided do not meet the medically necessary requirements indicated in the LCD for 
Medicare coverage. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive urine drug testing for 22 or more drug classes (G0483) provided July 26, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and electrocardiogram (93000) 
provided on February 9, 2022. 
 
You asked the Plan to pay for the evaluation and management services. You say that the services should be 
paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 15, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the evaluation and management services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99204) and 
electrocardiogram (93000) provided on February 9, 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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the 
enrollee's medical needs are being met in the current acute setting. 
 
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 appears to still be somewhat unstable but improving and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is 
currently unstable and as it would not be clinically advantageous at this time. Completion of treatment at the 
current facility is 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 long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on December 06, 2021. 
 
You asked the Plan to waive the copayment for ER visit. You say that this should be covered. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for ER visit. This item/service falls within the Emergency care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  
Therefore, we decided that the Plan does not have to waive the copayment for ER visit provided on December 
06, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health office visit provided on April 19, 2022. 
 
You asked the Plan to pay for an office visit. You say that you had authorization on file for this visit. The Plan 
denied your request. The Plan says this provider has opted out of Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a mental 
health office visit provided on April 19, 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. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 documentation shows that you do have active medical comorbidities however 
most therapy goals documented have been met. You would not be expected to require intense therapy with 
interdisciplinary team management of rehabilitation in an IRF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 to pay for the lab testing services provided on October 27, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the test is a covered benefit. The Plan denied your 
request. The Plan says the claim did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported. 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 to pay for the lab 
testing services provided on October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that the documentation justifies the services performed. 
The Plan denied your request. The Plan says the specimen was obtained in an office setting. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory 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 the lab services provided on January 27, 2022.