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

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on August 15, 2021. 
 
  You asked the Plan to pay for services provided at 24-hour facility, in addition to basic service (99053). You 
say that the correct CPT and ICD10 codes were billed, and no changes are required. You say that the attached 
documentation should be reviewed and reconsidered for payment. The Plan denied your request. The Plan says 
procedure code 99285 has been overturned and procedure 99053 remains denied as bundled services are not 
eligible for separate reimbursement. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic service 
(99053) provided on August 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that these items work for you. You also 
say that you are on a fixed income. The Plan denied your request. The Plan says the requested items are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional in-home support service hours per week. 
 
You asked the Plan to pre-approve additional in-home support service hours. You say that you have anxiety 
and panic attacks. You say that your mental health requires more benefit hours due to companionship. You also 
say that you would like 2 addition hours per week. The Plan denied your request. The Plan says additional 
hours beyond the benefit limit of 30 hours per year are not covered. 
 
Medicare generally does not cover in-home support services. However, the Plan offers an in-home support 
benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an in-home support benefit in excess of Medicare coverage, the requested additional 2 
hours per week exceed the limit of 30 hours per year. Therefore, we decided that the Plan does not have to pre-
approve 2 additional in-home support service hours per week.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from January 20, 2022, to 
January 27, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the acupuncture services. You say that you feel that this should be approved 
because there is not anyone that is close by to get acupuncture and this OON provider is the closest. The Plan 
denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that 
the services were not authorized by the Plan prior to being rendered, nor were they urgent or emergent in 
nature. 
 
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 
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 the acupuncture services provided from January 
20, 2022, to January 27, 2022 by an out-of-network (OON) provider.
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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that the patient was admitted for agitation, trouble ambulating, and metastatic 
prostate cancer. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not 
a reasonable expectation that this patient 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service February 23, 
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 February 23, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that the enrollee has requested to have Gel-One injection 
over the other preferred products. The Plan denied your request. The Plan says this request does not meet the 
Plan's Part B step therapy criteria for the requested viscosupplement device. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary. Our physician reviewer found there is no indication that the 
patient has tried and failed the required drugs. Our reviewer also found that there is no indication that the Plan's 
required drugs would likely be less effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 21, 2022.
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 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 76705 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 76705 billed for date of service January 21, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve MRI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the denial of authorization for this service is correct, because the Plan 
has not received records to show why this test is needed. 
 
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 MRI. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested MRI. Our physician reviewer found abdominal MRI as 
requested is the standard of care for further characterization of an indeterminant liver lesion greater than 1 
centimeter. Since the enrollee's liver lesion may be a hemangioma, tissue sampling is too risky. This MRI will 
also facilitate interrogation of the enrollee's indeterminant renal focus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the abdomen.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 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 Synvisc-One is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have left 
knee pain due to primary osteoarthritis of the left knee. The progress note dated My 25, 2022 states the x-rays 
"look very good" and that therapy is directed for treatment of a possible knee meniscus tear. Your pain is likely 
related to the meniscal tear; therefore, the requested Synvisc-One is 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 Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection (ESI).
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 an ESI is covered when specific criteria are met. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a history of headaches, neck and upper back pain, and a pinched nerve (radiculopathy) in your neck spine. You had spinal surgery with ongoing arm pain. There is no documentation that you have tried and failed four weeks of non-invasive conservative care. The criteria for coverage are not met and the cervical ESI is not reasonable or medically necessary at this time. 
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 cervical epidural steroid injection (ESI).
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 service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the member's medical conditions are stable and there are no complex nursing or 
rehabilitation needs.  While the member may have a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. 
 
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. Specifically, medically necessary services can be 
obtained in a lower level of care. This means admission into an IRF is not medically necessary Therefore, we 
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 
services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen (74183).
You asked the Plan to pre-approve an MRI. You say that this MRI is medically necessary to rule out other potential diagnoses. The Plan denied your request. The Plan says the criteria for coverage of this service are not met.
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 an MRI. Our reviewer says that the requested imaging service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has hepatitis C induced decompensated cirrhosis with varices and portal vein thrombosis. The record provided does not include a recent alpha-feto protein or ultrasound report and is insufficient to support the need for the requested test at this time. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen (74183).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530 and 
A6539. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have a leakage in your leg 
veins and your physician requested that you wear these items for 30 days prior to surgery. The Plan denied 
your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 and 
A6539 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530 and A6539.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 17, 
2021, to May 21, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says this admission was done purely for social reasons to get 
the patient placed into a facility. He had no acute medical issues that warranted hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the patient was brought to the emergency room (ER) on May 14, 2021, due to 
unsafe living conditions. The patient had no complaints, was at baseline and did not want to come to the ER. 
Per the ambulance records, the patient had food in the fridge and was being bathed by his caregiver. There were 
no acute medical issues. Per the ER physician notes, patient has benign exam, no complaints. There is 
documentation that patient was to stay in ER until Monday when placement could be arranged. This was 
clearly an admission for social issues. He was admitted on May 7, 2021. Home medications for his chronic 
medical conditions were resumed. There was no new onset of neurological deficits or abnormal findings on 
imaging and no planned interventions. The patient remained stable throughout the rest of his hospitalization 
while placement was arranged.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 17, 2021, to May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, physical therapy services and x-ray provided 
on March 14, 2021. 
 
You asked the Plan to pay for the office visit, physical therapy services and x-ray. You say that you are on a 
fixed income and cannot afford to pay out-of-pocket. The Plan denied your request. The Plan says the office 
visit, physical therapy and x-ray remain denied as non-covered chiropractic services. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit, physical therapy services and x-ray provided on March 14, 
2021.