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

 
We decided that the Plan does not have to pre-approve Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that you need the requested drug to treat your Crohn's 
disease. You say that you have been on this medication for 7 years. The Plan denied your request. The Plan 
says they are unable to verify whether the criteria for coverage of the requested drug have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, information must be submitted to corroborate the documentation in the beneficiary's 
medical documentation and to 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 Remicade have been met. Specifically, 
there are no medical records in the case file for us to review. Without medical records we cannot make a 
determination as to whether the requested drug is medically necessary.  Therefore, we decided that the Plan 
does not have to pre-approve Remicade.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebroplasty of the L1 and L5 vertebrae 
for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this procedure is needed for the enrollee. The 
Plan denied your request. The Plan says that there is no imaging that supports compression fractures at either 
level. 
 
The Plan must follow Medicare rules. Medicare rules say that PVA can be covered if the Medicare criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no evidence 
the fractures are acute and less than 6 weeks old. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebroplasty of the L1 and L5 vertebrae for the enrollee.
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 you are currently at an inpatient level of care and 
are showing that you are able to go to a SNF for continuing care. The Plan denied your request. The Plan says 
you do not meet Medicare criteria for coverage. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not 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 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 reduce the deductible for an office visit provided on September 20, 
2021. 
 
You asked the Plan to reduce the deductible for an office visit. You say that the doctor you saw accepts your 
insurance. Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The 
Plan also says that both providers are out of network. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to out of network provider services.  
 
 
  The record shows the provider you saw on September 20, 2021, is an out of network provider. The item or 
service you asked the Plan to reduce deductible for falls within the Physician/Practitioner Services, Including 
Doctor's Office Visits benefit category provider services. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to out of network provider services. This 
cost sharing is a contractual obligation that had not been met at the time an office visit was received on 
September 20, 2021. Therefore, we decided that the Plan does not have to reduce the deductible for an office 
visit provided on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periprostatic placement of biodegradable material. 
 
You asked the Plan to pre-approve placement of biodegradable material. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because the record does not show the type of radiation treatment planned or that the disease affects the 
enrollee's daily living. 
 
The Plan follows Medicare rules. Medicare rules state that use of prostate rectal spacers may be covered when 
certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve placement of biodegradable material. 
Our reviewer says that the enrollee does not meet the Medicare criteria for periprostatic placement of 
biodegradable material. Our physician reviewer found Medicare specifies that use of rectal spacer material is 
covered only for conventional fractionation or moderate hypofractionation, not prior to stereotactic body 
radiation therapy (SBRT). The enrollee's estimated prostate volume is 126cc, but a prostate volume greater than 
80cc is a coverage exclusion criterion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of biodegradable material have not been met. Therefore, we decided 
that the Plan does not have to pre-approve periprostatic placement of biodegradable material.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve home health. You say that you cannot get around as well as reported by 
your provider and feel that not continuing physical therapy will put your health at risk. The Plan denied your 
request. The Plan says the denial of authorization for continued home health skilled therapy is correct. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health. Our reviewer says that 
you do not meet the Medicare criteria for the requested home health care. Our physician reviewer found there is 
no documentation that further skilled therapy services are required to effectively provide treatment, care, and/or 
services in order to improve your level of function or establish/perform a maintenance program. The records do 
not document any acute or unstable medical conditions or changes in medication/treatment which would 
necessitate further skilled 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 home health have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100, 00142) provided August 2, 2019. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was not 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 anesthesia services was not filed until December 2, 2021. 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 anesthesia services (99100, 00142) provided August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from August 17, 2021, through 
September 17, 2021. 
 
You asked the Plan to pay for the medical services. You say that you believed these claims would be fully 
reimbursed. The Plan denied your request. The Plan says non-emergent services received out of the country 
will not be covered. 
 
  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that the 
only services that will be covered when outside the country are emergency room or emergency hospital 
admission.   
 
We looked at the file and Medicare rules. In this case, the services that you received that were emergency 
services have already been paid. The remaining services that have been denied are office visits and testing 
services that are not among those covered according to the Plans contract. Based on this information, we 
decided that Medicare rules for coverage of the medical services have not been met according to their coverage 
policy for services outside the country. Therefore, we decided that the Plan does not have to pay for the 
medical services provided from August 17, 2021, through September 17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284) provided January 17, 
2021. 
 
You asked the Plan to pay for the emergency room services. You say that the emergency room 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 emergency room services (99284) 
provided January 17, 2021. have not been met. Additional clinical documentation was requested by the plan to 
support the billed CPT code, and none was provided. Therefore, we decided that the Plan does not have to pay 
for emergency room services (99284) provided January 17, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the Magnetic resonance (eg, proton) imaging (MRI) services provided 
on September 30, 2021. 
 
You asked the Plan to pay for the MRI 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. 
 
You were referred for the MRI services by a contract provider. The file does not show that the Plan provided 
notice that the MRI services would not be covered. Under Medicare rules, this means the MRI services are 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the Magnetic resonance 
(eg, proton) imaging (MRI) services provided on September 30, 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: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on October 19, 2021. 
 
You asked the Plan to pay for the psychotherapy. You say that the attached medical records should be 
reviewed, and the claim processed toward payment. The Plan denied your request. The Plan says that there was 
no documentation of contact with the primary care physician in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a Clinical Social Worker (CSW) 
may be covered when the provider meets certain coverage criteria.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the claim indicates that these services were 
rendered by a CSW. There is no Medicare criteria indicating that a CSW must communicate with the member's 
treating physician. The Plan has not forwarded any additional evidence to substantiate why these services are 
not payable. Therefore, we decided that the Plan has to pay for psychotherapy provided on October 19, 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 lab testing services provided on July 19, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were compliant with regulations. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The file shows that Guardant360 testing was provided. The claim lists a place of service as an independent 
laboratory. The records do not show that the specimen was obtained at an independent laboratory. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on July 19, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical 
therapy and occupational therapy services but based on the medical records provided you do not require an 
intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different 
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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram services provided on June 22, 2021. 
 
You asked the Plan to pay for the services provided. You say that the service provided was contemporaneous. 
The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 93042 is Rhythm ECG, 1-3 leads; interpretation and 
report only. We find that CPT code 93042 was billed with CPT code 12013. The claim does not show that CPT 
code 93042 was billed with a modifier suitable for payment. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the electrocardiogram services provided on June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that this is medically necessary due to the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for a 
continuous glucose monitor (CGM). 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on April 30, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 99285 was billed with CPT code 29515. We looked at the file and the rules. We 
find that CPT code 99285 may be eligible for payment when billed with this code pair. The claim does not 
show that the code at issue was billed with a modifier suitable for payment. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the emergency room services provided on April 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 51785 and 95861 billed with the 
59-modifier provided on November 3, 2020. 
 
You asked the Plan to pay for the medical services as coded. You say that this claim is supported by the 
medical documentation. The Plan denied your request. The Plan says Medicare coding regulations have not 
been followed for the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
 
 In this case, the CPT Code Manual definition of code 51785 is needle electromyography studies (EMG) of anal 
or urethral sphincter, any technique. The CPT Code Manual definition of code 95861 is needle 
electromyography; 2 extremities with or without related paraspinal areas. 
 
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 medical services as coded. Our reviewer says that the 
documentation does not support payment for the services as billed. Our reviewer found the documentation is 
insufficient to support payment for CPT code 51785. The report does not describe placement of a pad or needle 
in the anal or urethral sphincter and measurement of electrical activity with the bladder filled and during 
emptying. Furthermore, procedure code 95861-26-59 is documented in the operative note. However, this 
procedure is inclusive to CPT code 95939-26 and the use of the 59 modifier is not warranted as the procedure 
is not separate and distinct procedure. 
 
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 medical services as coded have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services coded 51785 and 95861 billed with the 59-modifier provided 
on November 3, 2020.