Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 review has determined that the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on 
September 20, 2021, to September 29, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network services provided to the enrollee on 
September 20, 2021, to September 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided to the enrollee 
on November 3, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed in this case. 
 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 magnetic resonance imaging (MRI) provided to the enrollee on 
November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ECG (93000) and outpatient clinic visit (G0463) 
provided on June 29, 2021. 
 
You asked the Plan to pay for the ECG (93000) and outpatient clinic visit (G0463). The Plan denied your 
request. The Plan says CPT code 93000 denied due to status indicator M for a service not payable under the 
Outpatient Prospective Payment System (OPPS). The Plan also says that CPT code G0463 is also denied due to 
the billing error with CPT code 93000. 
 
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 93000 is electrocardiogram, routine ECG with at least 12 
leads; with interpretation and report. The CPT Code Manual definition of code G0463 is hospital outpatient 
clinic visit for assessment and management of a patient. 
 
We find that CPT code 93000 is not supported in the medical record. Specifically, CPT code 93000 has a status 
indicator M. This means that CPT code 93000 is not payable under OPPS. Since CPT code 93000 was denied, 
CPT code G0463 is also denied. Based on this information, we decided that Medicare rules for coverage of the 
ECG (93000) and outpatient clinic visit (G0463) have not been met. Therefore, we decided that the Plan does 
not have to pay for the ECG (93000) and outpatient clinic visit (G0463) provided on June 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision of excessive skin and subcutaneous tissue 
(includes lipectomy); abdomen, infraumbilical panniculectomy. 
 You asked the Plan to pre-approve the services. You say that fluid is building up in the stomach. The Plan 
denied your request. The Plan says this is 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has undergone a ventral hernia repair. The provided record indicates 
that the requested procedure is being performed for cosmetic purposes. The elements of the coverage criteria 
are not satisfied. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve excision of excessive skin and subcutaneous tissue (includes lipectomy); abdomen, 
infraumbilical panniculectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit billed on February 4, 2021. 
 
You asked the Plan to pay for the telehealth visit billed. You say that the treatment sought is medically 
necessary based on the patient's medical condition. You say that the treatment sought was a covered service 
and the service should be approved. The Plan denied your request. The Plan says there is no established 
relationship with the ordering provider and the requested documentation was not received. 
 
  The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, 
must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment. The rules say that the information submitted by the supplier or provider must corroborate 
the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria 
have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the telehealth visit billed have not been met. Specifically, sufficient medical records were not 
submitted to determine if a visit took place. Therefore, we decided that the Plan does not have to pay for the 
telehealth visit billed on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 review has determined that the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care.  
 You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99336) provided on November 2, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that you would like reconsideration because it is the 
responsibility of the facility to verify member eligibility. The Plan denied your request. The Plan says these 
services were not urgent, emergent or 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 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 rest home visit (99336) provided on November 
2, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life2000 system. 
 
You asked the Plan to pre-approve the Life2000 system. You say that bilevel positive airway pressure (BiPAP) 
is not sufficient for treatment of chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. 
The Plan denied your request. The Plan says a home mechanical ventilator with settings that could be delivered 
by bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 Life2000 system. Our reviewer says 
that the Life2000 system is not medically reasonable and necessary. Our physician reviewer found the 
Life2000 system is not a true ventilator, because it is not capable of providing full ventilatory support. It is meant to be used during activity, rather than during sleep. There is inadequate evidence to support a benefit of 
this device in the treatment of COPD. Also, the enrollee does not meet criteria for coverage of a home 
ventilator. She has severe COPD, but BiPAP has not been tried at home. 
 
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 Life2000 system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Life2000 system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on July 12, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the member's face-to-face service was rendered in a laboratory 
setting. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing (81479) provided 
on July 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic analysis of cochlear implant, age 7 years or older; 
subsequent reprogramming (CPT 92604) provided on September 20, 2021. 
 
You asked the Plan to pay for diagnostic analysis of cochlear implant, age 7 years or older; subsequent 
reprogramming. The Plan denied your request. The Plan says that hearing aids, hearing tests or examination for 
the purpose of prescribing, fitting, repair, or changing hearing aids are excluded from coverage and not a 
covered benefit in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for diagnostic analysis of cochlear implant, age 
7 years or older; subsequent reprogramming. Our reviewer says that the requested diagnostic analysis of 
cochlear implant, subsequent reprogramming is considered medically reasonable and necessary in this case. 
Our physician reviewer found that based on available clinical documentation, the requested services for 
cochlear implant reprogramming are medically reasonable and necessary. Cochlear implant follow-up 
programming after activation is an accepted, standard part of auditory rehabilitation. A review by Shapiro and 
Bradham (Otolaryngol Clin North Am, 2012) stated that after the first year post-activation, reprogramming 
sessions typically occur at 3-month intervals, though sessions may occur sooner if the patient exhibits a 
change in auditory responsiveness or a decrement in speech production. The enrollee presented with a 
complaint of distorted hearing in the left ear just over one year after activation of the revised cochlear implant, 
and cleaning and reprogramming the device resulted in good and improved hearing. In summary, the requested 
services for cochlear implant reprogramming appear medically 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 diagnostic analysis of cochlear implant, age 7 years or older; subsequent 
reprogramming have been met. Therefore, we decided that the Plan has to pay for diagnostic analysis of 
cochlear implant, age 7 years or older; subsequent reprogramming (CPT 92604) provided on  
September 20, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis rendered on October 26, 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 separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 81003 (urinalysis without scope) and 81001 (urinalysis 
with scope). Code 81003 is a column II code with a modifier indicator of 1 when billed with column I code 
81001. Code 81003 was not billed with an appropriate modifier to allow for separate payment. Therefore, we 
decided that the Plan does not have to pay for the urinalysis rendered on October 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance angiography of the 
head provided on October 19, 2021. 
 
You asked the Plan to waive the copayment for the magnetic resonance angiography. You say that you were 
not aware of the higher copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for diagnostic radiology services, including MRI's.  
 
 
 You have been asked to pay a $100 copayment for the magnetic resonance angiography. The magnetic 
resonance angiography 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 copayment for a magnetic resonance 
angiography of the head provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of a new patient (99326) rendered by the out-of-network (OON) provider on August 9, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new patient 
(99326) rendered by the out-of-network (OON) provider on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network 
(OON) provider on October 25, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on  
October 25, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee's medical status does not currently require intensive physician and 
nursing oversight in an IRF. While the enrollee may benefit from additional multiple therapies, including 
physical and occupational therapy, the documentation does not reveal that the enrollee requires this therapy or 
can tolerate this therapy on an intensive IRF level. The enrollee is noted to be deconditioned, short of breath 
with any exertion and having fatigue in therapy. 
 
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.