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

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen with 
contrast (74160). 
 
You asked the Plan to pre-approve a CT scan of the abdomen. You say that you disagree with the denial. The 
Plan denied your request. The Plan says this test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has pancreatic cysts less than 1.5 cm in size that have been stable upon most recent imaging in 
January 2022. The provided records do not indicate the medical necessity or reasonableness, as defined by 
Medicare rules, of the requested service at this time. There is insufficient literature to support the performance 
of the requested test at this time. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
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 CT scan of the abdomen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen with contrast (74160).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from March 25, 
2021, through March 28, 2021, at the Diagnosis Related Group (DRG) 917 originally billed. 
 You asked the Plan to pay for the inpatient hospital services billed at DRG 917. You say that you are 
requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says they 
are upholding their decision to replace diagnosis code G92 with F11.921 which results in a change from  
DRG 917 billed to DRG 918. 
 
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, the provider billed the inpatient services provided with diagnosis code G92 as defined by toxic 
encephalopathy. 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 DRG 917 originally billed. Our reviewer says that the inpatient hospital care provided was not billed 
correctly. Our physician reviewer found that the review indicates that the enrollee's issues were related to a 
drug overdose. The records did not support diagnosis code G92 as defined by toxic encephalopathy. The 
documentation supports DRG 918.  
 
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 the inpatient hospital services provided from March 25, 2021, through March 28, 2021, at the Diagnosis 
Related Group (DRG) 917 originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95907, 95886, and 95887 billed for date of 
service August 11, 2022. 
 
You asked the Plan to pay for procedure codes 95907, 95886, and 95887. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 95907, 95886, and 95887 is bundled 
into payment for code 95870. 
 
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 
95907, 95886, and 95887 are a column II code to column I code 95870 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 procedure codes 95907, 95886, and 95887 
billed for date of service August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found products currently classified as HCPCS 
code E0466, when used to provide continuous positive airway pressure (CPAP) or bi-level PAP (with or 
without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS 
payment category. A ventilator is not eligible for reimbursement for any of the conditions described in this 
RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions 
described in this RAD policy will be denied as not reasonable and 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Interfyl injection. 
 
You asked the Plan to pre-approve the injection.. You say that this is medically necessary. The Plan denied 
your request. The Plan says experimental and investigational procedures are not covered. 
 
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 injection.. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this is an experimental/ investigational use of this preparation.  Therefore, the request is 
deemed not medically reasonable and 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 injection. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Interfyl injection.
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 this is medically necessary. The Plan denied your 
request. The Plan says the records do not show skilled needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs. You do not require skilled 
nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility 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 skilled nursing facility (SNF) care.
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 does not meet 
criteria. 
 
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 enrollee was admitted for a urinary tract infection and acute renal insufficiency. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 does not meet 
criteria. 
 
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 enrollee was admitted for a stroke. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 provided on June 9, 2022. 
 
You asked the Plan to pay for code 99222. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable 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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, it is not 
appropriate to report inpatient evaluation and management service and place of service 21 when the enrollee's claim history shows that the patient was in an outpatient hospital observation status for this date of service. 
Based on this information, we decided that Medicare rules for coverage of code 99222 have not been met. 
Therefore, we decided that the Plan does not have to pay for code 99222 provided on June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician standby services provided on July 21, 2022. 
 
You asked the Plan to pay for physician standby services. You say that the surgeon believed the services were 
needed at the time of the patients surgery on the said date of service. The Plan denied your request. The Plan 
says standby services are not payable to physicians. Physicians may not bill Medicare or beneficiaries for 
standby services. Payment for standby services is included in the Part A payment to the facility. Such services 
are a part of hospital costs to provide quality care.  
 
The Plan must follow Medicare rules. Medicare rules say that standby services are not payable to physicians. 
Physicians may not bill Medicare or beneficiaries for standby services. 
 
We looked at the file and Medicare rules. Medicare says standby services are not payable to physicians. 
Physicians may not bill Medicare or beneficiaries for standby services. Therefore, we decided that the Plan 
does not have to pay for physician standby services provided on July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 10, 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 covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, an Aptima Vaginitis Panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires, (e.g., apnea monitor), per pair (A4557) 
provided June 29, 2022. 
 
You asked the Plan to pay for the lead wires. You say that the prescribing physician recommends an extended 
lifetime use of equipment as they are diagnosed with chronic pain and compromised mobility without the 
option for surgical correction. The Plan denied your request. The Plan says there is no evidence to support the 
ordering provider is ordered the service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering provider 
indicated and was informed that there is no record for the order for this enrollee. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the lead wires, (e.g., apnea monitor), per pair (A4557) provided June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous airway pressure (CPAP) device (E0601) 
purchased March 8, 2022. 
 
You asked the Plan to pay for the CPAP device. You say that there were no in network providers who had a 
CPAP machine in stock. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
Per Medicare Guidelines, Medicare pays the Supplier to rent the machine for the 13 months if youve been 
using it without interruption. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
You have been asked to pay $839.00 for the CPAP device. Medicare and the Plan will only cover the rental of 
devices from approved suppliers and will not cover the cost of purchasing a device. This item/service falls within the Durable Medical Equipment (DME) 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 pay for the continuous airway pressure (CPAP) device (E0601) purchased March 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee to help 
maximize the enrollee's level of independence. The Plan denied your request. The Plan says the enrollee does 
require intensive therapy services which can be meet a lower 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 the enrollee's functional status is at a home care level for rehabilitation. The enrollee 
does not require intensive rehabilitation or frequent physiatry oversight. Admission to IRF 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 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from May 26, 2022, to  
July 28, 2022. 
 
You asked the Plan to pay for psychotherapy services. You say that you were not informed by the Plans Member 
Services that the providers you receive services from must be Medicare-eligible and participate in the Medicare program. 
The Plan denied your request. The Plan says this provider is not a Medicare-certified provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist 
(MFT). Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from 
May 26, 2022, to July 28, 2022.