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

 
We decided that the Plan has to pre-approve ten (10) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says that the documentation does not support clinically 
significant improvements, and the documentation does not show that the enrollee requires further intervention 
from a skilled therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional PT visits. Our reviewer says 
that the requested therapy visits are reasonable and necessary in this case. Our physician reviewer found the 
provided clinical documentation specifically states continuation of therapy goals and maintenance therapy 
goals which would require the skills of a professional therapist as opposed to a home exercise plan. Therefore, 
the ten (10) additional physical therapy sessions are 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 additional PT visits have been met. Therefore, we decided that the Plan has to 
pre-approve ten (10) additional physical therapy (PT) visits.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services (97530) provided on August 
28, 2021. 
 
You asked the Plan to pay for occupational therapy services. You say that you have provided medical records 
to support the services billed. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as 
services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. In this case, the record shows that the services of an OTA have been 
billed as services incident to a physician/NPP's service. Based on this information, we decided that Medicare 
rules for coverage of occupational therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for occupational therapy services (97530) provided on August 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT, head or brain; without contrast material (CPT code 
70450) provided on February 4, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered 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. 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 CT, head or brain; without contrast material (CPT code 70450) 
provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastroenterology services with an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve the OON gastroenterology services. You say that the recommended doctor 
is a scam and only wants to perform procedures. You say that the other two network doctors are too far for you 
to drive. You say that the requested OON doctor is five miles away. The Plan denied your request. The Plan 
says the enrollee needs to receive necessary care from a network provider. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
 
 
 The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide the OON gastroenterology 
services. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided 
that the Plan does not have to pre-approve gastroenterology services with an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (CPT code 0037U) 
provided on December 22, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. The next generation 
sequence testing (NGS) testing panel performed included testing for the FANCC gene. Testing for this gene is 
not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels that include 
the FANCC gene are statutorily excluded service. Therefore, we decided that the Plan does not have to pay for 
targeted genomic sequence analysis (CPT code 0037U) provided on December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (CPT code 0037U) 
provided on December 28, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. The next generation 
sequence testing (NGS) testing panel performed included testing for the FANCC gene. Testing for this gene is 
not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels that include 
the FANCC gene are statutorily excluded service. Therefore, we decided that the Plan does not have to pay for 
targeted genomic sequence analysis (CPT code 0037U) provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on November 1, 2021. 
 
You asked the Plan to pay for the services. You say that this hould be paid for. The Plan denied your request. 
The Plan says that these codes are reimbursed to anesthesia providers only. 
 
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 provider of the service in this case was a certified registered nurse 
anesthetist. The plan has not provided any rationale for why that provider type is not appropriate. Therefore, we 
decided that the Plan has to pay for anesthesia services provided to the enrollee on November 1, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
August 18, 2021, to August 29, 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 payment of DRG 682 is not supported.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 682 (RENAL FAILURE WITH MCC). 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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
review indicates that the documentation supported an admission for hyponatremia. While the patient presented 
to the hospital with multiple acute conditions, the guideline for selection of principal diagnosis when there are 
two or more diagnoses would need to be followed. There is no evidence of a change in mental status which is 
beyond baseline. Documentation was unclear that mental status changes were due to metabolic issues. DRG 
641: MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND 
ELECTROLYTES WITHOUT MCC is the appropriate DRG.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from August 18, 2021, to August 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Vertiflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of this device for this enrollees medical condition. 
 
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 insertion of a Vertiflex device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colonoscopy, flexible; with removal of tumor(s), polyp(s), or 
other lesion(s) by hot biopsy forceps (CPT code 45384) provided on February 12, 2022. 
 
You asked the Plan to pay for the service. You say that 45384 is billed with modifier 59 and should be paid and 
not denied as bundled. You state that modifier 59 is the most appropriate modifier per Medicare's guideline. The Plan denied your request. The Plan says both CPT Codes 45385 and 45384 have the same Endobase of 
45378, which makes them belong to the same family. The Plan states 45385 and 45384 are reported with the 
same base procedure and has a MULT PROC Code of 3. The Plan states even though the provider billed a 
modifier of 59, this does not meet the Medicare rules for coverage of services 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. 
 
CPT code 44385 is a Column 1 code, while 44384 is a column II code in the Procedure-to-Procedure (PTP) 
edits. The claim has not been billed with the appropriate modifier to bypass the edit. The payment for Line 2 is 
bundled into line 1. Hence, the claim was processed and paid correctly. Therefore, we decided that the Plan 
does not have to pay for colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot 
biopsy forceps (CPT code 45384) provided on February 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on December 13, 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 that these codes are reimbursed to anesthesia providers only. 
 
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 has not provided a rationale as to why the rendering provider type is 
not valid for this service. The provider is a certified registered nurse anesthetist. The plan has not substantiated 
their denial. Therefore, we decided that the Plan has to pay for anesthesia services provided to the enrollee on 
December 13, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infrared pulse therapy services. 
 
You asked the Plan to pre-approve infrared pulse therapy. You say that this treatment is working for you, and it 
will help cure your dry eye. The Plan denied your request. The Plan says these services are not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that the use of infrared and/or near-infrared light and/or heat is not 
covered for any indication. Therefore, we decided that the Plan does not have to pre-approve infrared pulse 
therapy services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 27, 2021, 
through September 29, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an 
inpatient level of care was not medically necessary. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record shows that at the time of the inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 27, 2021, through 
September 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left/right heart catheterization procedure. 
 
You asked the Plan to pre-approve the left and right heart catheterization. You say that it is felt that this 
treatment is necessary. The Plan denied your request. The Plan says there is no need for this intervention at this 
time. 
 
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 left and right heart catheterization. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the patient had a radionuclide stress test suggestive of a small-moderate 
reversible defect. In absence of congestive heart failure, pulmonary hypertension, or valvular heart disease, 
guidelines do not support a need for right and left heart catheterization in this setting. As a result, at this time, 
right and left heart catheterization would not be considered medically appropriate and necessary in this 
patients 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 the left and right heart catheterization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a left/right heart catheterization procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the services of home health/hospice aide in home health 
or hospice settings, each 15 minutes (CPT code G0156) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health services. Our physician 
reviewer found the documentation does not support that you require additional skilled nursing services or 
skilled rehabilitation services to provide treatment that is medically necessary. You do not require additional 
skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your 
condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have 
been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. There 
is not a skilled need for the services, and the documentation does not support that additional home health aide hours are required. The requested home health services are not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the services of home health/hospice aide in home health or hospice settings, each 
15 minutes (CPT code G0156) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 15, 2021, to 
November 18, 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 that the inpatient admission was not medically 
necessary and the patient could have been appropriately managed in observation care. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was a then 75-year-old woman with chronic hypotension and diabetes on 
Midodrine and Florinef. She presented to the emergency room on November 15, 2021, with lower back pain 
radiating to the right leg and difficulty with ambulation. She was evaluated and admitted. She was treated for 
pain with medications and physical and occupational therapy and her diabetes was monitored. She was 
discharged on for further rehabilitation at a skilled nursing facility. The record showed that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier emergency room and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from November 15, 2021, to November 18, 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.