Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a caudal epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve the ESI. You say that the requested injection is medically necessary for the 
enrollee. The Plan denied your request. The Plan says a repeat ESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatment with epidural steroid injections (ESI) that 
extend beyond 12 months requires that the ESI provides at least 50% sustained improvement of pain and/or 
50% objective improvement in function. 
 
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 ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee experienced at least 50% pain relief for 3 months. Therefore, the reviewer found that 
the requested ESI 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 the ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a caudal epidural steroid injection (ESI) (62323).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs more time in physical therapy 
before she can go home. The Plan denied your request. The Plan says the enrollee can receive the care they 
need in another setting. 
 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 the enrollee is medically stable and no specific recommendation for frequency or 
rationale of skilled nursing assessment is documented. The documentation does not show that enrollee requires 
daily skilled services in a SNF. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a cardiac implanted loop recorder (ILR). 
 
You asked the Plan to pre-approve the ILR placement. You say that the patient requires this service to continue 
cardiac monitoring. The Plan denied your request. The Plan says the records do not support that continued ILR 
monitoring is reasonable and 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 the ILR placement. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is whether the requested authorization for explant of the patients old ILR 
and placement of a new ILR is medically necessary. The patient has had no further symptoms, and the ILR has 
shown no significant arrhythmias. In summary, there is insufficient documentation to support the medical 
necessity for insertion of a replacement ILR in this patients 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 ILR placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of a cardiac implanted loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator provided to you on May 27, 2022. 
 
You asked the Plan to pay for the oxygen concentrator. The Plan denied your request. The Plan says this 
provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator provided to you 
on May 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (procedure code 97140) provided to the 
enrollee on June 24, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the -59 modifier is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
record describes manual therapy and manual traction on the back. In this case, the service was performed on 
the same anatomical region and therefore would not be reported separately. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for therapy services (procedure code 97140) provided to the enrollee on June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on April 21, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99153 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on April 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291 and 99292) billed for date of 
service February 27, 2022. 
 
You asked the Plan to pay for critical care. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says these services are not supported 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, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The CPT Code Manual definition of code 99292 is 
critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 
minutes (List separately in addition to code for primary service). 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, the medical 
records provided do not note the time that the billing provider spent rendering these services. Without this information, we cannot verify the time-based codes at issue. Based on this information, we decided that 
Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care services (99291 and 99292) billed for date of service February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for automatic external defibrillator provided 
on June 14, 2022. 
 
You asked the Plan to waive the coinsurance for automatic external defibrillator. You say that you are 
disputing the share cost. 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. The allowed amount of this automatic external 
defibrillator total $3,080.95, resulting in a coinsurance amount of $616.19. 
 
You have been asked to pay 20% coinsurance for automatic external defibrillator. This item/service falls within 
the durable medical equipment and related supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for automatic external defibrillator provided on June 14, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 4 home health aide visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health services. Our reviewer 
says that the services are medically necessary. Our physician reviewer found clinical documentation shows that 
the enrollee has had recent clinical and functional status change (with recent fracture) and the doctor specifies a 
treatment plan including home health aide visits. Thus, 4 home health aide visits is medically appropriate. 
 
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 services have been met. Therefore, we decided that the Plan has to 
pre-approve 4 home health aide visits.  
 
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 procedure code 10035 billed for date of service May 13, 
2022. 
 You asked the Plan to pay for procedure code 10035. 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 10035 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 10035 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 10035 billed for date of service May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4310, A4311, A4331, A4332, A4338, 
A4354, and A4357 billed for date of service February 23, 2022. 
 You asked the Plan to pay for procedure code A4310, A4311, A4331, A4332, A4338, A4354, and A4357. You 
say that you disagree with the denial. The Plan denied your request. The Plan says payment for codes A4310, 
A4311, A4331, A4332, A4338, A4354, and A4357 is bundled into payment for code A4314. 
 
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 codes 
A4310, A4311, A4331, A4332, A4338, A4354, and A4357 are column II codes to column I code A4314. 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 
procedure codes A4310, A4311, A4331, A4332, A4338, A4354, and A4357 billed for date of service February 
23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you wish to have your request approved in an effort 
to increase your capacity to perform activities of daily living and decrease caregiver burden. The Plan denied 
your request. The Plan says this request does not meet criteria for an IRF level of care. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care 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 IRF admission and services.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services billed for April 30, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the required 
Q code was not billed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
The claim was denied as a Q code was not billed. However, Q codes are only required on a home health 
prospective payment system (HH PPS) claim, per guidelines outlined in Section 40.2. The claim at issue is a 
notice of admission claim. The Medicare Claims Processing Manual, Section 40.1 for Notice of Admissions, 
does not indicate a Q code is required. Based on this information, we decided that Medicare rules for coverage 
of the billed services have been met. Therefore, we decided that the Plan has to pay for the home health 
services billed for April 30, 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 definitive drug testing (G0483) billed for date of service July 
13, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service is supported in the medical record. The 
Plan denied your request. The Plan says this service is not supported 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, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers, 22 or more 
drug class(es), including metabolite(s), if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the record lists only 18 
drugs which were tested, some of which are within the same drug class(es). The records do not support that 22 
or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for definitive drug 
testing (G0483) billed for date of service July 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not processed by the primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has attempted to 
obtain an Explanation of Benefits (EOB) from the primary insurer on four separate occasions. As the secondary 
insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on 
May 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) services rendered on June 17, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure codes 93005 and 93041 have an OPPS status 
indicator of Q1(S) and were billed with code 99285, which has an OPPS status indicator of V. Codes 93005 
and 93041 are therefore not separately payable. Therefore, we decided that the Plan does not have to pay for 
the electrocardiogram (EKG) services rendered on June 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patent foramen ovale (PFO) closure device. 
 
You asked the Plan to pre-approve a PFO closure device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PFO closure device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of migraine headaches. While there have been published 
reports on the use of PFO closure devices for this indication, randomized controlled studies assessing efficacy 
remain inconclusive and the FDA has consequently not approved use of the device for this indication. As such, 
guidelines would not support the need for a PFO closure device. In summary, there is insufficient 
documentation to support the medical necessity for the requested PFO closure 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 a PFO closure device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a patent foramen ovale (PFO) closure device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for partial thromboplastin time (PTT) (85730) provided on July 
5, 2022. 
 
You asked the Plan to pay for PTT. You say that this service was medically necessary and should be paid. The 
Plan denied your request. The Plan says this service was not medically necessary for the enrollee's condition. 
 
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 pay for PTT. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found no specific clinical rationale was provided for the PTT. The review has determined that the 
items/services at issue in this case were not medically reasonable or 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 PTT have not been met. Therefore, we decided that the Plan does not have to 
pay for partial thromboplastin time (PTT) (85730) provided on July 5, 2022.