Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that you believe continuing therapy is 
necessary and beneficial. The Plan denied your request. The Plan says there is no evidence that the enrollee 
will make any additional improvements with the 6 additional visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional requested therapy generally is not accepted as 
specific and effective therapy for the patients condition beyond what was approved by the health plan. The 
patient has had prior PT and the documentation does not reveal that the patient requires the unique skills of a 
professional therapist to safely and effectively provide treatment, or that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. Our reviewer found that 
the patient has been educated in a home exercise program. Our physician reviewer also found that the requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current 
condition or to prevent or slow further deterioration. 
 
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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 services are not medically necessary. Our physician reviewer found the records show that you had 
worsening of back pain with paraspinal tension. There is no documentation of a subluxation of the spine. The 
criteria for coverage of chiropractic therapy are not met and the services are therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Tadalafil tablet. 
 
You asked the Plan to pre-approve Tadalafil. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Tadalafil 
tablet.  
 Benefits for Tadalafil may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on April 20, 2021. 
 
You asked the Plan to pay for therapeutic exercises. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 92526 and 97110. This PTP edit has a modifier indicator of 
1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed as required by Medicare coding regulations. 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 97110 
is a column II code to column I code 92526. 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 therapeutic exercises (97110) provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided from May 12, 2021, to 
July 8, 2021. 
 
You asked the Plan to pay for the services provided. You say that you are requesting reimbursement. The Plan 
denied your request. The Plan says the claim processed correctly. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The file shows that you received manual manipulation (code 98941) from an out-of-network provider. The 
provider charged $55 for this service, which is less than the $60 copay. Because the amount charged is less 
than the out-of-network copay, there is nothing for the Plan to reimburse.  
 
The file also shows you received office visits and x-rays. These services are not manual manipulation of the 
spine. This means that the services are not a covered benefit when they are performed by a chiropractor.  
Therefore, we decided that the Plan does not have to pay for the chiropractic services provided from May 12, 
2021, to July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary, rest home visit provided on December 7, 2021. 
 
You asked the Plan to pay for domiciliary, rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for domiciliary, rest home visit provided on December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the heart (75571) 
provided on December 8, 2021. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says an appropriate modifier was not billed with 
this claim as required by Medicare rules. 
 
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 75571 
is a column II code to column I code 71260. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the heart (75571) 
provided on December 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional outpatient physical therapy (PT) visits 
(97139 x10). 
 
You asked the Plan to pre-approve the additional PT visits. You say that your provider has sent over a necessity 
letter for 48 units to be added on to the already approved services. The Plan denied your request. The Plan says 
upon completion of the additional 2 visits that are approved, you will no longer meet medical necessity criteria 
for continuation of outpatient PT services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional 10 requested therapy generally is not accepted 
as specific and effective therapy for your condition. You have had prior extensive PT and the documentation 
does not reveal that you require the ongoing unique skills of a professional therapist to safely and effectively 
provide treatment, or that the services can be safely and effectively performed only by a therapist, or by or 
under the supervision of a therapist beyond what was approved by the health plan. Our reviewer found that you 
should be able to transition to an independent home exercise program (HEP). Our physician reviewer also 
found that the requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
your current condition or to prevent or slow further deterioration. 
 
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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional outpatient physical therapy (PT) visits (97139 x10).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on April 11, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you had a diabetic seizure. You say that you 
were not able to speak or move. You say that your husband called 911. You also say that you thought you 
would have a copayment and your insurance would cover the rest. The Plan denied your request. The Plan says 
since there was no payment provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 11, 2021. The ambulance benefit is a 
transportation benefit.  
 
 
 When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided 
that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on 
April 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on April 30, 2021. 
 
You asked the Plan to pay for therapeutic exercises. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 92526 and 97110. This PTP edit has a modifier indicator of 
1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed as required by Medicare coding regulations. 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 97110 
is a column II code to column I code 92526. 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 therapeutic exercises (97110) provided on April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultralightweight wheelchair (K0005). 
 
You asked the Plan to pre-approve ultralightweight wheelchair. You say that this specific wheelchair is 
necessary as you leave your home and get in and out of vehicles. The Plan denied your request. The Plan says 
the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is specifically being requested for use outside of the home. Although this item 
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pre-approve ultralightweight wheelchair (K0005).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planing (D4341 x 4) provided from 
September 8, 2021, to September 22, 2021 by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 
you would be reimbursed for these services. You say that you were not expecting to be reimbursed initially. 
You say that the closest in network provider was 16 miles away and this provider was only 10 minutes away. 
You also say that you feel you should be reimbursed 50% for the services. The Plan denied your request. The 
Plan says the records do not support that you were approved for out of network periodontal services with this 
provider. The Plan also says that the claims were denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the scaling and root planing (D4341 x 4) provided from September 8, 2021, to September 22, 2021 by the out 
of network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion/specialty drug administration, per visit 
(99601) provided on May 17, 2021. 
 
You asked the Plan to pay for the home infusion therapy. You say that the service was necessary. You also say 
that full payment should be made. The Plan denied your request. The Plan says procedure codes with Status 
Code of I are not payable for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 99601 has a Status Code of "I", 
indicating that this code is not valid for Medicare purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to 
pay for the home infusion/specialty drug administration, per visit (99601) provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records document some right upper 
extremity spasticity, which may be a contraindication to the requested deice. Although records from the device 
vendor argue medical necessity of the requested device, no records from the enrollees actual treating provider 
clarify why the requested device is the most appropriate treatment for the enrollees condition. Furthermore, 
current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched 
conventional upper limb exercise therapies" with unproven benefit in the home environment. The MyoPro is 
therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro powered arm brace.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
You asked the Plan to pre-approve epidural injection and facet joint injections. You say that you are appealing 
with supporting records. The Plan says that the denial of authorization for these services is correct, because it is 
not necessary to perform multiple blocks during the same session as epidural steroid injections. 
 
We decided that the Plan has to pre-approve epidural injection. We also decided that the Plan does not 
have to pre-approve facet joint injections. 
 
The Plan follows Medicare rules. Medicare rules state that epidural injections may be covered if certain criteria 
are met. Medicare rules also state that it is not medically reasonable and necessary to perform multiple blocks 
during the same session as epidural steroid injections.  
 
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 epidural injection and facet joint 
injections. Our reviewer says that the enrollee meets the Medicare criteria for the requested epidural injection 
but does not meet criteria for the requested facet joint injections. Our physician reviewer found Medicare 
precludes the performance of multiple blocks on the same day. The enrollee meets the criteria for an epidural 
steroid injection. Facet blocks cannot be performed on the same day as it may confuse the diagnostic picture. 
Further, facet block criteria emphasize that facet joint disease is an exclusion, so the epidural block should be 
performed first, and the results evaluated for the necessity of further interventions.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural injection have been met, but Medicare rules for coverage of facet joint 
injections have not been met. Therefore, we decided that the Plan has to pre-approve epidural injection but does 
not have to pre-approve facet joint injections. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary. The 
Plan denied your request. The Plan says authorization denied because LTACH is not medically necessary, and 
that the enrollee has several issues that need to be addressed in the inpatient setting prior to discharge to a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records, the enrollee has not completed full acute hospital 
course of care is not medically stable to transfer to an alternate level of care at this time. The documentation 
does not support that the enrollee requires services at the LTACH that are not available at the acute care 
hospital where they currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.