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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging (78815). 
 
You asked the Plan to pre-approve a PET with CT scan. You say that the PET with CT scan should be covered. 
The Plan denied your request. The Plan says the records show the enrollee has had four PET scans since 
October 2020, for stage III lymphoma and is during chemotherapy treatment without new signs or concerns for 
a need in chemotherapy changes. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET with CT scan. Our reviewer says 
that the PET CT scan is not medically reasonable and necessary. Our physician reviewer found that the enrollee 
has had greater than three PET CTs. If further imaging desired, CT can be done. PET CT is 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 PET with CT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) for attenuation correction and anatomical localization imaging (78815).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
can be received in-network. 
 
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 29, 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 the hospital discharge services rendered on September 8, 
2021. 
 
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 must follow Medicare rules. The rules say that only one hospital discharge day management service is 
payable per patient per hospital stay.  
 
We looked at the file and Medicare rules. The file shows that a discharge code was previously paid for this 
patient for the date of service at issue. 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 pay for the hospital 
discharge services rendered on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 14, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this code reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81599) provided on October 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with the incorrect date of 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 payment for CPT code 81599 is not supported in the medical record. Specifically, the lab services 
must be billed with the date the specimen was collected. The records show that the specimen was collect on 
May 10, 2021. This means that the claim was billed with the incorrect date of service. 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 the lab services (81599) provided on October 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presbyopia-correcting intraocular lens (P-C IOL) 
rendered on February 23, 2022, and March 30, 2022. 
 
You asked the Plan to pay for these services. You say that you needed the multi-focal lens over the standard 
lens. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia-correcting 
intraocular lens (P-C IOL) rendered on February 23, 2022, and March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on January 10, 
2022. 
 
You asked the Plan to pay for the provided services. You say that the enrollee is suffering long-standing 
diabetes. The Plan denied your request. The Plan says the documentation did not sufficiently support the billed 
supply code. 
 
The Plan must follow Medicare rules. The rules state that if the information in the patients medical record does 
not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The documentation does not indicate that the enrollee requires frequent self-adjustment of insulin 
dosage based on the blood glucose testing results or has had an in-person visit with their treating physician to 
assesses adherence to their diabetes treatment plan. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitor provided on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair. 
 
You asked the Plan to pay for a shower chair. You say that you would like to be reimbursed for this item. The 
Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of the VIA Disc allograft intervertebral disc 
augmentation in the setting of discogenic low back pain have not been demonstrated in the peer-reviewed 
literature. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this allograft is experimental. More research is needed to show safety and efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the VIA disc allograft intervertebral disc augmentation procedure.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an Arizona brace (L1940, L2330, L2820) for the enrollee. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items are covered 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 brace. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical documentation shows that the enrollee has ankle/foot deformity and difficulty 
ambulating, which is the criteria for an ankle foot orthosis. In addition, the enrollee requires protection of foot 
ulcer thus L1940, L2330, L2820 is medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the brace have been met. Therefore, we decided that the Plan has to pre-approve 
an Arizona brace (L1940, L2330, L2820) 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 16, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 19, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider should not be required 
to obtain authorization. The Plan denied your request. The Plan says the provider is out-of-network, there was 
no prior authorization, and the services were not urgent or emergent. 
 
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 subsequent nursing facility care provided on April 
19, 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 you need IRF care to return home safely. The Plan 
denied your request. The Plan says criteria for admission to the IRF setting have not been met. Your ongoing 
skilled therapy and nursing needs can be provided at 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services rendered from January 19, 2022, to January 
31, 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 that the claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the claims were not billed correctly; however, there is no 
further explanation or documentation stating exactly how the claims were incorrectly billed. The Plan has not 
provided any specific Medicare rules to support that the claims are not payable as billed. Therefore, we decided 
that the Plan has to pay for the home health services rendered from January 19, 2022, to January 31, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee does not require an intensive rehabilitation therapy 
program that requires physician supervision by a rehabilitation physician. Services the enrollee needs can be 
provided at home with physical therapy or at a skilled nursing facility (SNF). 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. The enrollee does not need 3 hours a day, 5 days a week of therapies with multidisciplinary 
approach in an IRF while the participation is limited. 
 
Documentation does not support the medical necessity due to lack of medical complexity and nursing needs for 
admission to an IRF. While the enrollee would benefit from physical therapy and occupational therapy the 
enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as 
continuation in the SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing procedures provided on December 6, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you are an independent laboratory and have billed 
the services at issue with the correct POS code. The Plan denied your request. The Plan says that rules for 
payment have not been met because the POS code is incorrect. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided relevant medical records to support its 
assertion that the services at issue were billed with the incorrect POS code. It is the Plan's responsibility to 
substantiate its denial. In this case, the denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for genetic testing procedures provided on December 6, 2021.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9128 billed for date of service March 20, 
2022. 
 
You asked the Plan to pay for procedure code S9128. You say that this should be covered The Plan denied your 
request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 
 
 We find that procedure code S9128 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9128 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9128 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9128 billed for date of service March 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that the lab services at issue were 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 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 February 9, 2022.