Persius/hicric huggingface dataset:
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at 
the current hospital and can remain there until ready for discharge to a lower level of care, such as in a skilled 
nursing facility or at home with home health services. 
 
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 that the enrollee appears to be improving and should only require short-term 
additional acute care services that can safely be administered at the current facility until the enrollee is more 
stable and appropriate for a lower level of 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on January 6, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these 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 podiatry services provided on January 6, 2022 by 
an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Mental Health services provided on November 3, 
2021 to January 19, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Mental Health services. You say that you want to appeal the denial of 
coverage for my psychotherapist because you thought she was a networking provider. The Plan denied your 
request. The Plan says the provider is out-of-network and authorization is required prior to an out-of-network 
visit. 
 
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 Outpatient Mental Health services provided on 
November 3, 2021 to January 19, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of bilateral breasts 
with and without contrast. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has been treated for breast 
cancer. A PET/CT scan was performed on May 12, 2022 and showed no metastases and no recurrence of breast 
disease. There is no documentation of biopsy results showing a return of disease to the breasts or chest wall or 
that the doctor suspects the disease has returned due to unclear ultrasound results. The MRI is not reasonable or 
medically necessary for the enrollee 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 magnetic resonance imaging (MRI) of bilateral breasts with and without contrast.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group psychotherapy (90853) and the psychotherapy; 45 
minutes with a patient (90834) rendered by the out-of-network (OON) provider on October 15, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the group psychotherapy (90853) and the psychotherapy; 45 minutes with a 
patient (90834) rendered by the out-of-network (OON) provider on October 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 66250-79-LT and two units of code 68801-59 billed for 
date of service January 12, 2021. 
 
You asked the Plan to pay for code 66250-79-LT and two units of code 68801-59 billed for date of service 
January 12, 2021.. You say that these services were billed correctly. The Plan denied your request. The Plan 
says code 68801-59 is not appropriate because the use of the -59 modifier is not supported. In addition, code 
66250-79-LT billed on the claim is also not supported because it is bundled into code 66821 (which was paid) 
 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 66250-79-LT is revision or repair of operative wound of 
anterior segment, any type, early or late, major or minor for reimbursement consideration.  Code 68801 was 
billed with the -59 modifier. 
 
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 code 66250-79-LT and two units of code 68801-59 billed for 
date of service January 12, 2021. Our reviewer says that billing of these codes is not supported in the medical 
record. Our reviewer found for the two units of code 68801-59, the operative report does not include 
documentation of dilation of lacrimal punctum.  For code 66250, you reported revision or repair of operative 
wound anterior segment, separately from YAG laser capsulotomy. The operative report does not support these 
two procedures are distinct and therefore would not be reported separately.  Documentation describes revision 
of anterior segment performed with YAG laser in the same eye, so the modifier cannot be verified in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 66250-79-LT and two units of code 68801-59 billed for date of service 
January 12, 2021. have not been met. Therefore, we decided that the Plan does not have to pay for code 66250-
79-LT and two units of code 68801-59 billed for date of service January 12, 2021.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. 
 
 
 
 
  
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on October 5, 2021. 
 
You asked the Plan to pay for the services provided. You say that there was a need for additional advancement 
flap. The Plan denied your request. The Plan says the codes are not supported in the documentation. 
 
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 14060 is adjacent tissue transfer or rearrangement, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less. 
 
 
 We find that CPT code 14060 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgery services provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for genetic testing provided on December 3, 
2021. 
 
You asked the Plan to waive the coinsurance for genetic testing. You say that you were assured by letter that 
the procedure would be covered in total. The Plan denied your request. The Plan says the coinsurance applied 
was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Please note that the preapproval letter for your genetic testing states 
that you may still be responsible for copayments or coinsurance. Your contract with the Plan clearly says that 
you must pay a 20% coinsurance for in-network genetic testing provided in all service settings. The allowed 
amount of the claim is $3,873, resulting in a coinsurance amount of $774.60 ($3,873 x 20%). 
 
 
  You have been asked to pay $774.60 for genetic testing. Genetic testing falls within the outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for genetic testing provided on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00410) provided November 17, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 00410 is not supported in the medical record. Specifically, payment is determined based 
on the base unit of the anesthesia procedure with the highest base unit value. Another anesthesia code was 
already paid for this date of service. Based on this information, we decided that Medicare rules for coverage of 
the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services (00410) provided November 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 home health physical therapy visits. 
 
You asked the Plan to pre-approve 11 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 11 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care. As such, the requested, ongoing, home health physical therapy services 
are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 11 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 11 home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. The Plan denied your request. The Plan says 
an epidural steroid injection does not meet the Medicare coverage criteria 
 
The Plan follows Medicare rules.  
 
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 epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not medically necessary. Our physician reviewer 
found the enrollee has a diagnosis of sacroiliitis, for which an epidural steroid injection is not indicated. The 
review has determined that the requested epidural steroid injection does not meet the Medicare LCD coverage 
criteria. 
 
 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 7, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the sample to 
you to undergo testing and you would like the claim to be covered. The Plan denied your request. The Plan 
says the rendering and referring providers are both OON providers and there was no approved authorization. 
Also, the service rendered was 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 the laboratory services provided on January 7, 
2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left atrial appendage closure (LAAC) at the acute 
inpatient setting. 
 
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 LAAC 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 enrollee has had bleeding from 
external hemorrhoids after recent banding, but there has not been reassessment of the hemorrhoids to determine 
the next step in management or if there is superficial bleeding that would represent a contraindication to 
anticoagulation. As such, the LAAC is not supported as 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 left atrial appendage closure (LAAC) at the acute inpatient setting.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialty care transportation services (A0434, A0425) 
provided on December 29, 2021. 
 
You asked the Plan to pay for the transportation services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says this transportation would be bundled into the payment for the inpatient hospital care for this enrollee, because this service was provided while the enrollee was still admitted 
as inpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that once a beneficiary is admitted to a hospital, it may be necessary to transport the beneficiary 
to another hospital or site temporarily for specialized care while the beneficiary maintains inpatient status with 
the original provider. This movement of the patient is considered patient transportation and is covered as an 
inpatient hospital service and payment is made under Part A for that service. 
 
We find that the ambulance services are not supported for separate payment in this case. Specifically, the 
documentation shows that the enrollee was still admitted as inpatient on the date in question and was not 
discharged from the hospital until December 30, 2021. Based on this information, we decided that Medicare 
rules for coverage of the transportation services under Part B have not been met. Therefore, we decided that the 
Plan does not have to pay for the specialty care transportation services (A0434, A0425) provided on December 
29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services provided were medically 
necessary and you would like reconsideration of payment for the claim. The Plan denied your request. The Plan 
says the rendering and referring providers are both OON providers and there was no approved authorization. 
Also, the service rendered was 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 the laboratory services provided on February 10, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 a CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.