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

 
We decided that the Plan does not have to pre-approve a cardiovascular stress test (93015) with Lexiscan. 
 
You asked the Plan to pre-approve a cardiovascular stress test with Lexiscan. You say that you get this test 
done every year, and do not understand why it is not approved. The Plan denied your request. The Plan says 
based on the guidelines and documentation, you do not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular stress testing is not considered 
reasonable and necessary when the incremental information obtained from a repeat test or from the addition of 
an echocardiogram to an electrical stress test is of no clinical relevance or when a stress test is performed too 
frequently. 
 
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 cardiovascular stress test with 
Lexiscan. Our reviewer says that a cardiovascular stress test with Lexiscan is not medically reasonable and 
necessary. Our physician reviewer found you had a negative test in October of 2021. There is no evidence 
provided that would support the need for repeat radionuclide stress testing in the absence of any significant 
change in clinical condition. Our reviewer found that the clinical guidelines do not support repeating a single-
photon emission computerized tomography (SPECT) scan when the last study was normal in October 2021, 
with no intervening change in clinical status or new signs, symptoms or physical findings. Our physician 
reviewer also found that there is insufficient documentation to support the medical necessity for the requested 
cardiac stress testing in your 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 a cardiovascular stress test with Lexiscan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a cardiovascular stress test (93015) with Lexiscan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic facet injections. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not meet the coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
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 the enrollee has a history of chronic low back pain. He has difficulty standing and is unable 
to sit for a prolonged period without pain. Previous injections include medial branch blocks and radiofrequency 
ablation in 2021. According to the coverage criteria, therapeutic intra-articular facet injections are not covered 
unless there is documentation on why radiofrequency ablation (RFA) cannot be performed. In this case, the 
enrollee has undergone previous RFA procedures at the requested sites. There is no documentation on why 
RFA cannot be performed. The review has determined that the requested treatment is not indicated for the 
enrollee's condition. 
 
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 therapeutic facet injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that a SNF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of a SNF admission. 
 
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 skilled services are not required on a daily basis. Additionally, as a practical 
matter, the services are not required on an inpatient basis, only in a skilled nursing facility setting. The records 
do not support that services in the home 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 inpatient skilled nursing facility (SNF) care.
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 the enrollee needs therapy to get strong enough to 
go back home. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to a SNF and should remain in the acute care hospital. 
 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 the enrollee does not have documented skilled nursing or skilled therapy needs. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim device. 
 
You asked the Plan to pre-approve the requested services. You say that those with the device experienced 
improvement in the quality of life. The Plan denied your request. The Plan says the use of the device is not 
supported as standard of care. 
 
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 services. Our physician 
reviewer found that the enrollee has symptoms thought due to chronic systolic heart failure (CHF) despite 
medical management, in a setting of severely reduced left ventricular function. There remains an absence of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim 
Neo in patient management. As a result, at this time the Barostim Neo system would not be considered 
medically reasonable and necessary in this enrollees 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service July 16, 
2022, to August 12, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service July 16, 2022, to August 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
Specifically, you can move around with a cane and you do not have a mobility deficit that impairs your 
participation in MRADLs. 
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power scooter (K0800).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 26, 2021, 
through August 30, 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 they 
submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. The Plan says even though A41.9 is coded on the claim, the documentation received was inconsistent/unclear 
regarding this diagnosis and supporting medical record documentation was unable to be found. 
 
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 A41.9-Sepsis, unspecified organism. 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 physician reviewer found it appears based on the provided documentation that the enrollee did not have 
sufficient evidence of organ dysfunction directly related to a systemic infection and did not meet Sepsis 3 
criteria. Therefore, the diagnosis of sepsis was not sufficiently supported in the documentation.   
 
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 August 26, 2021, through August 30, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93770 billed for date of service April 19, 
2022. 
 
You asked the Plan to pay for procedure code 93770. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 93770 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 93770 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 93770 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 93770 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 93770 billed for date of service April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiologic examination, spine, cervical; 6 or more views 
(CPT code 72052), office or other outpatient visit for the evaluation and management of a new patient (99203 
and 99204) and office or other outpatient visit for the evaluation and management of an established patient 
(99212) provided from May 17, 2022, through June 1, 2022, performed by a chiropractor. 
 
You asked the Plan to pre-approve the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says they have limit chiropractic benefits, and these services are excluded. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve radiologic examination, spine, cervical; 6 or more views (CPT code 
72052), office or other outpatient visit for the evaluation and management of a new patient (99203 and 99204) and office or other outpatient visit for the evaluation and management of an established patient (99212) 
provided from May 17, 2022, through June 1, 2022, performed by a chiropractor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 29, 
2022 to May 28, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for skilled care for this period of time from April 29, 2022, to May 28, 2022. 
 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 pay for 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 the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 29, 2022 to May 28, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to lower the copayment for a follow up visit. We decided that the Plan does not 
have to lower the copayment for a primary care provider copayment.  
 You asked the Plan to lower the copayment for a follow up appointment provided on June 8, 2022, and June 
15, 2022. You say that this should be a $10 primary care office copayment, not the $20 specialist copayment. 
The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to lower the copayment for a follow up visit from $20 to $10.  
 
The Plan follows Medicare rules. Medicare rules say that there is a $10 copayment for primary care office 
visits. The file shows that you have a medical indication for which Medicare will cover primary care office 
visits. Therefore, we decided that the Plan has to lower the copayment for a primary care provider visit.  
 
We also decided that the Plan does not have to lower the copayment for a primary care provider 
copayment. 
 
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 $10 
copayment for a primary care office visit. Therefore, we decided that the Plan does not have to lower the 
copayment for a primary care provider copayment. You are being asked to pay a total copayment amount of 
$20 for these follow up visits ($10 x 2 visits = $20). 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intermittent limb compression device (CPT code E0675) 
provided from February 4, 2022, through March 2, 2022. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that the claim should be paid. 
The Plan denied your request. The Plan says Medicare rules say that CMS does not pay any provider or 
supplier other than the facility or hospital for services furnished to the beneficiary. The Plan states the facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made between the facility and hospital and outside providers. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Furthermore, the enrollee used the equipment in the 
facility during or after surgery. Payment for this service would have been included under the facility claim. 
Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we 
decided that the Plan does not have to pay for the intermittent limb compression device (CPT code E0675) 
provided from February 4, 2022, through March 2, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve continued neuropsychological testing evaluation services (96132). 
 
You asked the Plan to pre-approve neuropsychological testing evaluation services. You say that you feel that 
prior authorization for this testing should be approved so a diagnosis can be made, and a treatment plan made 
for you. The Plan denied your request. The Plan says that there is evidence of neurological degeneration and 
neuropsychological testing will not diagnose the cause or direct the treatment of memory loss or visual 
hallucinations. 
 
The Plan follows Medicare rules. Medicare rules say that neuro-cognitive, mental status, and speech testing is 
testing which is intended to diagnose and characterize the neurocognitive effects of medical disorders that 
impinge directly or indirectly on the brain. 
 
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 neuropsychological testing evaluation 
services. Our reviewer says that the neuropsychological testing is considered reasonable and medically 
necessary. Our physician reviewer found based on review of the records provided, it was noted that you had a 
magnetic resonance imaging of the brain on June 10, 2022, which showed signal abnormality and mild 
ventriculomegaly. You had an electroencephalogram which showed generalized neuronal disturbance 
considered mild toxic metabolic or degenerative encephalopathy. Our reviewer found you were considered for 
possible Lewy body dementia. You have shown impairment in functioning as documented. You have been 
showing difficulty with cognitive issues as outlined using the interpretation. Our physician reviewer also found 
that based on review of the records provided and the information provided, you do meet the criteria for 
neuropsychological testing. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing evaluation services have been met. Therefore, we 
decided that the Plan has to pre-approve continued neuropsychological testing evaluation services (96132).  
 
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.