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

 
We decided that the Plan has to pre-approve skilled nursing facility (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 enrollee does not meet criteria for SNF care and can be treated in a lower 
level of care such as at home with home health services or in a long-term care facility. 
 
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 
daily skilled physical and occupational therapy services that the enrollee requires can only be provided in a 
skilled nursing facility setting. Our physician reviewer found that the enrollee does have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee 
does have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total hip arthroplasty (27130) provided on September 17, 
2021. 
 
You asked the Plan to pay for the total hip arthroplasty (27130). You say that CPT code 27130 is a payable 
code. You say that the medical records should be reviewed, and the code reconsidered for payment. The Plan 
denied your request. The Plan says procedure code 20680 has been overturned and procedure code 27130 is not 
supported by the medical records submitted. 
 
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 27130 is arthroplasty, acetabular and proximal femoral 
prosthetic replacement (total hip arthroplasty), with or without autograft or allograft. 
 
We asked our coder 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 total hip arthroplasty (27130). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report does not include enough documentation to confirm a total hip arthroplasty was performed. 
Therefore, the procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the total hip arthroplasty (27130) have not been met. Therefore, we decided that 
the Plan does not have to pay for the total hip arthroplasty (27130) provided on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (62323). 
 You asked the Plan to pre-approve a repeat epidural steroid injection. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat epidural steroid injection. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee does not meet Medicare coverage criteria for a repeat ESI. 
 
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 repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the member does not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (76700) provided February 10, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed 
and is not eligible for separate payment. 
 
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 76700 
has a bundled relationship with code93976. 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 radiology services (76700) provided February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided February 10, 2022. 
 
You asked the Plan to pay for the radiology services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed 
and is 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 CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for radiology services (70450) provided February 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on September 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on September 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 the Computed tomography (CT) scan (70450) provided on 
January 16, 2022. 
 
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed.  
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 the Computed tomography (CT) scan (70450) provided on 
January 16, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services provided on February 10, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the provider did not tell you these services 
would not be covered. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the surgical services by a contract provider. As a contract provider, this provider is 
expected to know which services are covered and which are not. This provider is expected to know if they can 
bill for services provided to a Medicare-eligible enrollee. There is no evidence that this provider ever advised 
you that services they give to you would not be covered. Under Medicare rules, this means the surgical services 
are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the surgical services 
provided on February 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided August 19, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one CPT code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple CPT codes were submitted for a single panel. Another claim 
was submitted with multiple other CPT codes for this same specimen. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for genetic testing (81479) provided August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (36626) provided November 9, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this code is 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 CPT code. 
 
We find that CPT code 36626 is not supported in the medical record. Specifically, the services in this code are 
inclusive to code 61645 which was also billed. Based on this information, we decided that Medicare rules for 
coverage of the surgical services have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for surgical services (36626) provided November 9, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71045) provided January 25, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, this code has already been 
paid for this date of service. The records do not support an additional unit. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for radiology services (71045) provided January 25, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the office visit. We decided that the Plan does not 
have to waive the copayment for the visual field exam.  
 You asked the Plan to waive the copayments for the office visit and the visual field exam. You say that this is a 
follow-up to retinal surgery, and you should only have a $30 specialist copayment which included the retinal 
imaging. The Plan says that you have been asked to pay the correct cost sharing amount. 
 
We decided that the Plan has to reduce the copayment for the office visit.  
 
The record shows that you were overcharged for the office visit.  
 
The Plan says that you must pay a $36.13 copayment for the office visit. Based on the Plan contract however, 
you cannot be asked to pay more than a $30 copayment for the office visit. There, we decided that the Plan has 
to reduce the copayment for the office visit. 
 
We also decided that the Plan does not have to waive the copayment for the visual field exam. 
 
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 $75 
copayment for the visual field exam. Therefore, we decided that the Plan does not have to waive the copayment 
for the visual field exam. For this date of service, you have been asked to pay the allowed amount of the claim 
because this amount is less than the standard $75 copayment for the visual field exam. 
 
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 genetic testing (0239U) provided August 18, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. Records show the test was not ordered by the enrollee's treating 
physician. Based on this information, we decided that Medicare rules for coverage of the genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0239U) provided 
August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the wheelchair accessories. We decided that the Plan does not 
have to pre-approve the foot plate bracket and seat liner.  
 You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan says that the items are not medically necessary. 
 
We decided that the Plan has to pre-approve the electronic connection.  
 
The Plan follows Medicare rules. Medicare rules say that items that are medically necessary are 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 wheelchair accessories. Our 
reviewer says that the electronic connection is medically necessary. Our physician reviewer found the patient 
has less than anti-gravity strength, poor range of motion and coordination in upper limbs with a 
neurodegenerative 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 wheelchair accessories have been met. Therefore, we decided that the Plan 
has to pre-approve the electronic connection.  
 
We also decided that the Plan does not have to pre-approve the foot plate bracket and seat liner. 
 
The Plan follows Medicare rules. The rules say that Medicare will pay for durable medical equipment (DME) 
that is reasonable and necessary for treatment of an illness or injury, or to improve the functioning of a 
malformed body part. Medicare considers equipment to be reasonable and necessary if the equipment does not 
serve the same purpose as other equipment already available to an enrollee. You can find these rules in the 
Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 15, Section 110.1(C). 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has already been approved for the foot plate bracket assembly and seat liner 
with the base wheelchair, making this a duplicate request and not medically necessart.  Based on this 
information, we decided that Medicare rules for coverage of the foot plate bracket and seat liner have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the foot plate bracket and seat liner. 
 
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 the care management services (99336, 99490) provided on 
January 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the care management services. You say that you would like this claim 
reprocessed and approved for payment based on medical necessity. The Plan denied your request. The Plan 
says prior authorization was not obtained for these services rendered by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the care management services (99336, 99490) 
provided on January 17, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Precision Neo test strips. 
 
You asked the Plan to pre-approve Freestyle Precision Neo test strips. You say that these test strips would work 
better than the Plan's preferred brand. The Plan denied your request. The Plan says the Plan's preferred brand of 
test strips would be acceptable. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Freestyle Precision Neo test strips. 
have been met. In this case, no medical documentation was provided to indicate why the Plans preferred brand 
of test strips would not be sufficient. The Plan contacted your provider and confirmed the Plans preferred 
brand would be acceptable.  
  
 
Therefore, we decided that the Plan does not have to pre-approve Freestyle Precision Neo test strips.