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

 
We decided that the Plan does not have to pre-approve Transurethral Microwave Therapy (TUMT). 
 
You asked the Plan to pre-approve TUMT. 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 TUMT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the services are not medically necessary. Specifically, TUMT is not indicated for prostate 
glands that are larger than 100 cc as is the case here. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TUMT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Transurethral Microwave Therapy (TUMT).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the psychotherapy services (90832) provided on November 2, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that there is no referring physician listed 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have been met. Specifically, the record shows that the enrollee was 
referred to this provider by their attending/primary physician. Therefore, we decided that the Plan has to pay 
for the psychotherapy services (90832) provided on November 2, 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 surgical pathology rendered on January 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 surgical pathology 
rendered on January 11, 2021.
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 you do not meet the Medicare criteria for admission to an IRF. 
 
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. Medical problems are 
stable. 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 services (83789) provided on July 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 83789 
is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (83789) provided on July 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on April 27, 2021. 
 
You asked the Plan to pay for therapeutic exercises. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 92526 and 97110. 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 as required 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 97110 
is a column II code to column I code 92526. 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 therapeutic exercises (97110) provided on April 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is needed to treat the enrollee's chronic diarrhea. 
The Plan denied your request. The Plan says that this is not covered under Part B. 
 
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 Budesonide for the enrollee.  
 
Benefits for this 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health aide. 
 
You asked the Plan to pre-approve the home health aide. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a doctor must certify the need for home health 
care services.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health aide have not been met. Specifically, the documentation submitted does not 
include any evidence that the enrollees current physician or facility has certified the need for home health 
services. Therefore, we decided that the Plan does not have to pre-approve the home health aide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that you need the additional 
trips. The Plan denied your request. The Plan says additional transportation trips are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that coverage of routine transportation is not a covered benefit. Therefore, we decided that the Plan does not 
have to pre-approve the additional transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 13, 2020. 
 
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 billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for service(s) provided between 10:00 PM and 8:00 AM at 24-
hour facility, in addition to basic service (99053) provided March 31, 2021. 
 
You asked the Plan to pay for the after-hours services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says this code is assigned a status 
code B = bundled 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 
after-hours services 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 service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to 
basic service (99053) provided March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel provided on April 11, 2021. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim has not been billed per Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene 
CPT codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus Gene Panel have not been met. Specifically, it is not appropriate to bill this testing 
using individual gene CPT codes. Therefore, we decided that the Plan does not have to pay for the Tempus 
Gene Panel provided on April 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on December 1, 2021. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided records to 
support the level of service. The Plan denied your request. The Plan says rules for payment have not been met 
because the service at issue is included in another billed 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 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 a computed tomography (CT) scan of the head or brain (70450) 
provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the routine eye exam with eye refraction 
(92014, 92015) provided on September 21, 2021. 
 
You asked the Plan to waive the copayment for the routine eye exam. You say that this service should be 
provided with a $0 copayment. The Plan denied your request. The Plan says this claim was processed correctly, 
and your copayment was assessed in accordance with your contract. 
 
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 $35 
copayment for a routine eye exam.  
 
 
 You have been asked to pay a $35 copayment for the routine eye exam. 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 the routine eye exam with eye refraction (92014, 92015) provided on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a biventricular implantable cardioverter defibrillator 
(ICD) upgrade. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has exhibited a stable 
degree of left ventricular dysfunction, with ejection fraction estimated at 40 to 45 percent in 2020 and again in 
2021, without significant change. This degree of left ventricular function is above the 35 percent threshold 
cited by guidelines for biventricular pacing candidacy and likelihood of favorable response to bi-ventricular 
pacing. There is insufficient documentation to support the medical necessity for removal of the current 
defibrillator and replacement with a bi-ventricular pacemaker or defibrillator. 
 
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 a biventricular implantable cardioverter defibrillator (ICD) upgrade.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials rendered on September 
29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99072 (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) has a status indicator of B and has no separate Medicare payment. Therefore, we decided that the Plan 
does not have to pay for the additional supplies and materials rendered on September 29, 2021.
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 to go back to the hospital where there is 
always a medical doctor on call. You husband has health issues and is driving too far and you want to be closer 
to your home. The Plan denied your request. The Plan says the records do not support that the enrollee meets 
the criteria for the requested IRF services 
 
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 enrollee's 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 enrollee has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this enrollee 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on December 6, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on December 6, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve captropril tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has been on this 
medication since 2017. 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 
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 captropril tablets.  
 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 pre-approve therapeutic apheresis (36514). 
 You asked the Plan to pre-approve therapeutic apheresis. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested 
service have not been met. 
 
The Plan must follow Medicare rules. The rules say that apheresis is covered for the indications listed in the 
Medicare rules section.  
 
We looked at the file and Medicare rules. In this case, the requested service is prescribed for treatment of an 
indication not listed in the Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapeutic apheresis have not been met. Therefore, we decided that the Plan does not have to pre-
approve therapeutic apheresis (36514).