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

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of blood vessels and grafts of 
heart for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the doctor needs to give more information about the need for this test. 
 
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 the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has 
intermittent chest pain and shortness of breath, as well as mild aortic stenosis. She is on sublingual 
nitroglycerin for chest pain. Due to these facts, she qualifies for the requested CT coronary calcium scoring 
test. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of blood vessels and grafts of heart for the enrollee.  
 
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 an office visit provided on March 22, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 an office visit provided on March 22, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 99100) provided to the 
enrollee on December 9, 2021. 
 
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 this is always bundled into payment for other services not specified and no separate payment is 
made per Medicare. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99100 is not separately payable. 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 anesthesia 
services (procedure code 99100) provided to the enrollee on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81286, 81413, 81414, 81442, 81161, 81479) 
provided October 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that denies coverage for all cardiovascular risk 
assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented 
cardiovascular disease. 
 
We looked at the file and Medicare rules. cardiovascular risk assessment panels are not covered. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81286, 81413, 81414, 81442, 81161, 81479) 
provided October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient office visit. You say that you would like to see a different pain 
management provider. The Plan denied your request. The Plan says the records do not indicate that you have an 
emergent or urgent medical condition, or are in need of specialized service(s) that are not available in-network. 
The Plan also says that there are in-network provider(s) within a reasonable distance from your location that 
can provide this service or item. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an outpatient office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the request for this item is a duplicate. 
 
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 you already requested a CGM. The requested CGM has previously been approved by the 
Plan. This means that this request is considered a duplicate request. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service March 21, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 
is a column II code to column I code 93976. 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 code 76700 billed for date of service March 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 25, 2020, to December 31, 2020. 
 
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 DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 while it is acknowledged that the records include a physician-documented 
diagnosis of sepsis, and that Systemic Inflammatory Response Syndrome (SIRS) signs were present along with 
an elevated lactic acid, the clinical findings in the record do not sufficiently support the diagnosis of sepsis 
based on Sepsis 3 criteria. The review has determined that the records do not support that A41.9 - sepsis, 
unspecified organism - was supported in the medical records. The appropriate DRG is DRG 193: SIMPLE 
PNEUMONIA AND PLEURISY WITH MCC.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 25, 2020, to December 31, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements 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 the therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of you having undergone psychotherapy. There is no documentation of 
electroconvulsive treatment (ECT) or transcranial magnetic stimulation (TMS) in the past. You are not being 
treated for severe major depressive disorder. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcranial magnetic stimulation therapy.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there has not been six weeks of provider directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that while it is true that 
you have not had physical therapy, you do have leg weakness. Importantly, you have had left sacroiliac joint 
injection without any relief of symptoms. Under the considerations of medically necessity, there is a provision 
of medical necessity if you have had injected steroids without improvement, as is the case here. Together with 
the left leg weakness, the medical necessity of the requested MRI has been established. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the lumbar spine.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on March 
11, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you were told the provider was in-
network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $45 
copayment for each exam to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $45 copayment for the eye exam, which is the network rate. The eye exam falls 
within the Vision Care 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 copayment for a diagnostic 
eye exam provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for aortography provided to the enrollee on March 15, 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 that procedure code 75625 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 75625 is "aortography provided to the enrollee on March 15, 2022." 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the operative report clearly describes 
femoral artery puncture under ultrasound using the Seldinger technique. The guidewire was threaded into the 
aorta, after which aortagram and runoff were described in the technique. This was followed by positioning of 
the catheter into the contralateral iliac artery for runoff.  The procedure description is compatible with 
abdominal aortagram and serial films; thus, CPT 75625 was an appropriate code. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
aortography provided to the enrollee on March 15, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue 
(includes lipectomy); abdomen, infraumbilical panniculectomy services. 
 
You asked the Plan to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); 
abdomen, infraumbilical panniculectomy services. You say that you are trying to get this second part of your 
surgery to have more reduction. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that abdominal panniculectomy is only covered for certain 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve excision, excessive skin and 
subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy services. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found you have undergone weight loss and are still losing weight. The record does not 
provide documentation of efforts to treat intertrigo or functional important. Therefore, you do not meet criteria 
for the requested 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 excision, excessive skin and subcutaneous tissue (includes lipectomy); 
abdomen, infraumbilical panniculectomy services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, 
infraumbilical panniculectomy services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF stay provided from February 26, 2022, to March 26, 
2022. 
 
You asked the Plan to pay for the SNF stay. You say that the SNF stay was medically necessary. The Plan 
denied your request. The Plan says the enrollee did not receive any daily physical therapy, skilled therapy, or 
skilled nursing services during the DOS in question. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF stay. Our physician reviewer found 
that the enrollee did not have daily skilled nursing or therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional. Our physician reviewer found that based on the 
documentation provided, the enrollee no longer qualified for SNF coverage. 
 
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 SNF stay have not been met. Therefore, we decided that the Plan does not 
have to pay for a skilled nursing facility (SNF) stay provided from February 26, 2022, to March 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional magnetic resonance imaging (MRI) services 
provided to the enrollee on November 19, 2021. 
 
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 records do not indicate that a repeat procedure was performed. 
 
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 72146 is "Magnetic resonance (eg, proton) imaging, 
spinal canal and contents, thoracic; without contrast material." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found there was one magnetic resonance 
imaging (MRI) exam of the thoracic spine was done on 11/19/21, and verified by the doctor. No second exam 
is in the records. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional magnetic resonance imaging (MRI) services provided to the enrollee on November 
19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (J2001) provided September 21, 2021. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says records do not support the billed service. 
 
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 J2001 is not supported in the medical record. Specifically, the provided records do not 
support this service. Based on this information, we decided that Medicare rules for coverage of the injections 
have not been met. Therefore, we decided that the Plan does not have to pay for injections (J2001) provided 
September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home care services (T1019) provided October 23, 2021 to 
October 29, 2021. 
 
You asked the Plan to pay for the home care services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed code is not eligible for Medicare 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. 
 
We find that CPT code T1019 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code T1019 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the home care services have not been met. Therefore, we decided that the Plan does not have to 
pay for home care services (T1019) provided October 23, 2021 to October 29, 2021.