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

 
We decided that the Plan has to pre-approve a lumbar nerve block injection (CPT 64520). 
 
You asked the Plan to pre-approve a lumbar nerve block injection. You say that a lumbar nerve block injection 
is medically necessary. The Plan denied your request. The Plan says that the lumbar nerve block injections do 
not meet the Milliman Care guidelines. 
 
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 lumbar nerve block injection. Our 
reviewer says that the requested lumbar nerve block injection is considered medically reasonable and necessary 
in this case. Our physician reviewer found that ganglion impar block is diagnostic for perineal and rectal pain 
which maybe sympathetically mediated. The requested service is medically reasonable and 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 lumbar nerve block injection have been met. Therefore, we decided that the 
Plan has to pre-approve a lumbar nerve block injection (CPT 64520).  
 
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 waive the copayment for an x-ray of the chest provided on February 
18, 2022. 
 
You asked the Plan to waive the copayment for an x-ray of the chest. You say that the doctor 
recommended/referred you to get an echocardiogram and an x-ray. You also say that this should be covered by 
insurance. The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
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 for x-rays you must 
pay a $10 copayment for a primary care physician (PCP)'s office, a $35 copayment for a specialist's office, a 
$40 copayment for a free-standing radiology facility, and a $50 copayment for outpatient therapy.   
You have been asked to pay a $31.41 copayment for an x-ray of the chest. An x-ray of the chest falls within the 
Outpatient diagnostic tests and therapeutic services and supplies 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 an x-ray of the chest provided on February 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 31, 2022 billed with 
codes 81227, 81230, 81225, and 81226. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 31, 2022 billed with codes 81227, 81230, 81225, and 81226.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that medical treatment for the enrollee 
cannot be achieved at a lower level of care. The Plan denied your request. The Plan says that the requested 
inpatient care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the review indicates that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for outpatient psychotherapy services provided to the enrollee on January 
31, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that providers are required to furnish necessary information when requested. 
 
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 90832 is "Psychotherapy, 30 minutes with patient." 
 
We find that CPT code 90832 is supported in the medical record. Specifically, after the case file submission, 
the plan received a psychotherapy note for the date at issue in this case. The code is now supported. Based on 
this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we 
decided that the Plan has to pay for outpatient psychotherapy services provided to the enrollee on January 31, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth office visit received on February 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service is incorrect. 
 
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 99496 is "Transitional Care Management Services with 
the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge Medical decision making of high complexity during the service 
period Face-to-face visit, within 7 calendar days of discharge." 
 
This should have been billed with Place of Service (POS) 02, for telehealth provided other than in patient's 
home. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met.  
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for a telehealth office visit received on February 14, 
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can be met at a lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for a fall, hip pain, and foot drop. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar surgery. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has increased pain and 
symptoms with all movements. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that a lumbar surgery with an inpatient admission was requested. 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 requested services. Our physician reviewer found that there is 
no documentation of adequate physical therapy for back pain. More conservative measures are needed. 
Therefore, the requested surgery is not medically reasonable or necessary at this time. Services related to non-
covered services are not covered under Medicare. Therefore, the associated inpatient admission is also not 
covered.  
 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is necessary given the life-threatening 
nature of the enrollee's high risk prostate cancer. The Plan denied your request. The Plan says that PBRT is not 
the standard of care for prostate cancer. 
 
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. PBRT would exceed 
the patient's needs at this time. PBRT may not be better than IMRT/IGRT. Our physician reviewer found that 
the enrollee's condition does not meet 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. Therefore, we decided that the Plan does not 
have to pre-approve Proton Beam Radiation Therapy (PBRT) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services provided on March 4, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the service was medically necessary for the 
wellbeing of the enrollee. The Plan denied your request. The Plan says the code exceeds the allowable units of 
service. 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 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. The records show that the Plan has agreed to pay for 1 unit of service. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to further pay for the blood bank physician services provided 
on March 4, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided to the enrollee from September 11, 
2021, to October 21, 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 that payment is not allowed for this claim because it lacks a required qualifying visit code from a 
federally qualified health center. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The provider appears to have fixed the issue about matching the earliest date to 
bill. The plan has not provided a Medicare-approved citation as to why the clam requires a qualifying visit code 
from a federally qualified health center. The plan has not substantiated their denial. The plan has not provided 
explicit instructions on how the provider could correct the claim for payment. Therefore, we decided that the 
Plan has to pay for home health services provided to the enrollee from September 11, 2021, to October 21, 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 23, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the member cannot choose the radiologist 
who reads their report. The Plan denied your request. The Plan says the services were not urgent or emergent 
and the services could have been rendered by a Plan participating 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genetic testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the record indicates that the enrollee has an elevated prostate specific antigen. The record 
provided is insufficient to establish the medical necessity of the requested service. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the serum magnesium assay rendered on March 24, 2022. 
 
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 were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a serum magnesium assay is covered when 
specific criteria are met. 
 
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 the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of multiple 
myeloma in remission. The records do not support that the criteria for coverage are met and the testing was 
reasonable and medically necessary for the enrollee. 
 
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 pay for the serum magnesium assay rendered on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the virtual check-in (code G2012) you had with an out-
of-network doctor on April 26, 2022. 
 
You asked the Plan to pay more for the virtual check-in. You say that you paid $50 for this visit and were only 
reimbursed $11.66.  You feel as though the Plan should pay you more for this visit. The Plan denied your 
request. The Plan says reimbursed you correctly based on the Medicare-allowed amount for this service and 
your applicable cost sharing. 
 
The Plan must follow Medicare rules. Medicare rules say that this provider must accept the Medicare-allowed 
rate for the service provided. In this case, the Medicare-allowed rate for the service you received (G2012) is 
$14.57.  You have 20% coinsurance for these services under your Plan contract, so 20% of $14.57 ($2.91) was 
subtracted from your reimbursement amount, leaving you with a reimbursement of $11.66.  This is the exact 
amount that the Plan reimbursed you, so the Plan paid correctly for this service.  It appears as though this 
provider charged you more up front for this service than they should have. You have the right to go back to the 
provider and request a refund of the difference between the amount you paid up front and the Medicare-
allowed amount of $14.57. Therefore, we decided that the Plan does not have to pay more for the virtual check-
in (code G2012) you had with an out-of-network doctor on April 26, 2022.