Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a distal revision of a prior gastric bypass surgery. 
 
You asked the Plan to pre-approve the requested bariatric procedure. You say that you believe that this should 
be covered. The Plan denied your request. The Plan says this is not supported by the literature at this time. 
 
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 requested bariatric procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found distalization of the gastric bypass procedure is currently not a standard treatment 
for morbid obesity. There are limited studies on durable long-term outcomes with some publications noting risk 
of macronutrient malabsorption and need for reversal. 
 
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 bariatric procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a distal revision of a prior gastric bypass surgery.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomographic angiography (CTA) of the chest, 
abdomen, and pelvis. 
 
You asked the Plan to pre-approve a CTA of the chest, abdomen, and pelvis. You say that the enrollee has a 
known growing aneurysm in thoracic area, and the office believes it is imperative that a full 
chest/abdomen/pelvis computed tomography (CT) CTA be completed. The Plan denied your request. The Plan 
says that the enrollee does not meet the criteria for a CTA scan of the abdomen and pelvis. 
 
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 CTA of the chest, abdomen, and 
pelvis. Our reviewer says that a CTA of the chest, abdomen, and pelvis is medically reasonable and necessary 
for the enrollee. Our physician reviewer found report of a CTA of the chest, abdomen, and pelvis from March 
11, 2022, showed significant increase in size of distal thoracic aortic aneurysm now 8.6 cm in diameter. Such 
an increase in size mandates either intervention or close surveillance. Our reviewer found that the known 
findings of occlusion of the left iliac artery and the abnormal fem-fem graft provide indications for a CTA of 
the chest, abdomen, and pelvis in order to provide vital information in the event surgical treatment is 
contemplated. Our physician reviewer also found that the remainder of the aorta needs to be studied for 
potential surgical planning. 
 
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 CTA of the chest, abdomen, and pelvis have been met. Therefore, we decided 
that the Plan has to pre-approve a computed tomographic angiography (CTA) of the chest, abdomen, and 
pelvis.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
March 5, 2021, through March 11, 2021. 
 
You asked the Plan to pay for the SNF services. You say that you would like this claim reprocessed based on 
the medical records. The Plan denied your request. The Plan says this claim has not been filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the SNF services was not filed until July 20, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 5, 2021, through 
March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that a long-term loop recorder is clearly mandated for the 
enrollee because you believe they have symptomatic rhythm disturbances, but despite to two monitors, no 
definitive diagnosis can be made. The Plan denied your request. The Plan says this request is not medically 
necessary because the records show there is not a question of needing additional work up for the cause of the 
enrollee's lightheadedness. The Plan also says that it is not indicated that the replacement loop monitoring test 
results would impact the enrollee's medical management. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related, but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom 
MLR. 
 
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 an ILR. Our reviewer says that an ILR 
is not reasonable and necessary for the enrollee. Our physician reviewer found there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR. Our reviewer also found that there is insufficient documentation to support the medical necessity for 
insertion of an ILR in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 22, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 
0031U, 0032U, 0033U, 81479, 81407, 81406, 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records have been attached to 
this appeal. Please have a look at the attachment and reconsider the charges which were previously denied. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 
April 22, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81355, 81335, 81401, 0031U, 0032U, 0033U, 81479, 81407, 81406, 81238.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee revision surgery to be provided in an out-of-
network (OON) hospital. 
 
You asked the Plan to pre-approve the surgical procedure in an OON facility. You say that you need this 
surgery urgently, and your surgeon feels the OON facility is necessary. You state that you have had your prior 
surgeries at this facility. The Plan denied your request. The Plan says there is no medical reason that the 
required surgery cannot be performed at a network hospital. Your surgeon does have privileges at the network 
hospital as well. 
 
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. There is no specific information given by 
your doctor stating why the network facility is not adequate. 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 
knee revision surgery to be provided in an out-of-network (OON) hospital.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there is no documented need for daily skilled therapy services. Based on the 
medical records provided there is no documentation that you require the services on an inpatient basis, only in a 
skilled nursing facility setting. The records do not support that outpatient therapy or services in the home or an 
assisted living facility with home health care or in a long-term care facility on a part time basis are not 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64483 billed for date of service February 16, 
2022. 
 You asked the Plan to pay for procedure code 64483. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 64483 is 1. The MAI value for this code is 2. You billed 2 units each of 
code 64483-RT and 64483-LT, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of procedure code 64483 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 64483 billed for date of service February 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on March 5, 2021. 
 
You asked the Plan to pay for an emergency department visit. You say that the primary payment that was 
issued was recently recouped by the payer due to their records indicating that they are not the primary carrier. 
The Plan denied your request. The Plan says Medicare denies a claim for untimely filing if the receipt date 
applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an emergency department visit was not filed until June 16, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit provided on March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, an injection of a diagnostic or therapeutic 
substance, a triamcinolone acetonide injection provided on July 13, 2022, to July 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit, an injection of a diagnostic or therapeutic substance, a 
triamcinolone acetonide injection. You say that the cost of this should be covered in full. The Plan denied your 
request. The Plan says this provider is not a network provider with the Plan. The Plan also says that the services 
were not referred by a network provider or rendered in a participating facility. The Plan also says that these 
services were not approved in advance. 
 
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, an injection of a diagnostic or 
therapeutic substance, a triamcinolone acetonide injection provided on July 13, 2022, to July 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested service is considered experimental in nature. The reviewer found that 
there is not enough research. Therefore, the reviewer found that the requested Intracept procedure is not 
medically 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup for a machine to treat sleep apnea. 
 
You asked the Plan to pre-approve a battery backup. You say that the battery is necessary. The Plan denied 
your request. The Plan says alternative power sources are not considered by Medicare as durable medical 
equipment. The Plan states Medicare does not allow payment for power generators or alternative power sources 
needed in the event of power outages. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve a battery backup for a machine to treat sleep 
apnea.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on February 14, 
2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens 
and/or targets.  
 
We looked at the file and Medicare rules. In this case, the panel was not billed with one unit of service as 
required by LCA A58577. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
pathogen panel provided 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 you need IRF care. The Plan denied your request. 
The Plan says you do not need the intensive services provided in 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. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, a pneumococcal polysaccharide vaccine, and 
an electrocardiogram provided on February 22, 2022, to June 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, a pneumococcal polysaccharide vaccine, and an 
electrocardiogram. You say that the provider is in-network. The Plan denied your request. The Plan says there 
were in-network provider who could have provided the services. The Plan also says that the services were not 
preauthorized. 
 
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, a pneumococcal polysaccharide 
vaccine, and an electrocardiogram provided on February 22, 2022, to June 15, 2022, by an out-of-network 
(OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 6 PT visits. You say that additional PT is needed because the enrollee is still 
showing reduced range of motion and strength. The Plan denied your request. The Plan says the beneficiary can 
continue your home exercise program without the guidance of a licensed therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 6 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the documentation does not support the need for additional 6 
physical therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six (6) additional physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from April 9, 
2022, to April 14, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that this charge is far too much on 
your income. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment per day, for days 1 to 6 for inpatient services ($325 per day x 5 days = $1625).  
 
The enrollee has been asked to pay a $1625 copayment for an inpatient stay. This item/service falls within the 
inpatient services benefit category. This means that the enrollee has been asked to pay the correct amount based 
on the contract with the Plan.  This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for an inpatient stay provided from April 9, 
2022, to April 14, 2022.