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

 
We decided that the Plan does not have to pre-approve imaging guidance for radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that daily ultrasound guidance is required 
for field placement. The Plan denied your request. The Plan says radiation therapy guidance is not needed for 
the enrollee's skin cancer. 
 
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 requested services. Our physician 
reviewer found that the treatment itself is not disputed in this case but rather the need for image guidance. 
When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. 
Daily simple simulations and/or IGRT for a technology for which need has not been established by published 
data or supported by consensus guidelines. Daily simulations or IGRT would not be furnished in accordance 
with accepted standards of medical practice. 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve imaging guidance for radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage services coded 10180 provided on 
October 13, 2021. 
 
You asked the Plan to pay for the incision and drainage services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are 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 CPT code. 
 
We find that CPT code 10180 is not supported in the medical record. Specifically, surgery procedure 22015 
(incision and drainage services) was provided on July 30, 2021. This surgery procedure has a global surgery 
period of 90 days. This means that procedure code 10180 was billed within the global surgery package of code 
22015 and is therefore, not payable as billed.  
 Based on this information, we decided that Medicare rules for coverage of the incision and drainage services 
have not been met. Therefore, we decided that the Plan does not have to pay for the incision and drainage 
services coded 10180 provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a neurostimulator (63650). 
 
You asked the Plan to pre-approve implantation of a neurostimulator. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met because the requested service is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that payment may be made for the implantation of dorsal 
column or depth brain stimulators or services and supplies related to such implantation only when the criteria 
listed in the Medicare rules section of this letter have been 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 implantation of a neurostimulator. Our 
reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that the request does not meet coverage criteria because there is no psychological evaluation. 
Additionally, the request is for a second trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a neurostimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve implantation of a neurostimulator (63650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on May 12, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported by 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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, the documentation does not 
support testing of a non-drug analyte as indicated in the code description of the code billed. In addition, the 
medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Based on this information, we decided that Medicare rules for coverage of the mass spectrometry and 
tandem mass spectrometry services have not been met. Therefore, we decided that the Plan does not have to 
pay for the mass spectrometry and tandem mass spectrometry services coded 83789 provided on May 12, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 9, 2022. 
 
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 this processed and denied correctly. 
 
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 the denied codes is: 
 
CPT 80061: 
 
Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct 
measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) 
 
CPT 80053: 
 
Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total 
(82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) 
Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) 
Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea 
nitrogen (BUN) (84520)  
CPT 84484: 
 
Troponin, quantitative 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the denied procedures were 
automated procedures performed by a laboratory technologist, and is read by the treating physician, and in this 
case a professional modifier would not be covered. 
 
We looked at this coder'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 pay for laboratory services provided to the enrollee on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92012) provided on June 6, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a medical eye examination. You say that you are not obligated to obtain 
authorization and the service should be covered. The Plan denied your request. The Plan says the service was 
performed by a non-participating provider and services from non-participating providers are not covered unless 
preauthorized. 
 
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 a medical eye examination (92012) provided on 
June 6, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are high fall risk and bedsore will lead to sepsis 
without proper care which you cannot do yourself. The Plan denied your request. The Plan says the request 
does not meet Medicare guidelines because you are receiving adequate and necessary intensive rehabilitation in 
the Inpatient Rehabilitation Facility. All the services you need are offered at the IRF. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 the enrollee meets the full criteria for an IRF stay. 
The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met and the 
services the enrollee's needs can be provided in another setting like a skilled nursing facility. 
 
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 clinical documentation shows that the enrollee has functional impairments 
and IRF compliant diagnosis however there are no documented active comorbidities that would require 
continued inpatient hospitalization during rehabilitation (post op hypoxia and encephalopathy documented as 
being resolved). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. In this case, research is needed before coverage 
can be approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on April 12, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that this should be covered. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 office visit (99214) provided on April 12, 2022, by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy evaluation coded 97167 provided 
on September 16, 2021. 
 
You asked the Plan to pay for the occupational therapy evaluation. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported by 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 97167 is occupational therapy evaluation, high 
complexity, requiring these components: An occupational profile and medical and therapy history, which 
includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or 
psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more 
performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an 
analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of 
multiple treatment options. Patient presents with comorbidities that affect occupational performance. 
Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable 
patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or 
family. 
 
We find that CPT code 97167 is not supported in the medical record. Specifically, the documentation shows 
that these services were performed by a qualified occupational therapist in the home health or hospice setting. 
This means there is a more appropriate code to be billed for the services rendered. Based on this information, 
we decided that Medicare rules for coverage of the occupational therapy evaluation have not been met. 
Therefore, we decided that the Plan does not have to pay for the occupational therapy evaluation coded 97167 
provided on September 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99310) provided on January 
17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were rendered in good 
faith and medically necessary. The rendering physician depends upon the hospital staff to verify eligibility and 
to obtain the proper authorization from the patients insurance. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless they are authorized by the Plan before the 
services are provided.  
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 (99310) provided 
on January 17, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the Medicare criteria for IRF admission were not met 
and the enrollee's medical needs can be provided at a lower level of care like 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 supervision 3 times a week in an IRF or intensity of care in a long-term acute care 
hospital (LTACH). There are no acute rehabilitation nursing needs identified or documented. The enrollee does 
not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. The enrollee needs physical therapy and occupational therapy in an 
alternate setting. 
 
The documentation does not support necessity for admission to an IRF or an LTACH due to lack of medical 
acuity/ complexity and nursing needs. Not medically necessary or reasonable. While the enrollee may benefit 
from physical therapy and occupational therapy, the enrollee's rehab needs can be provided in a lower intensity 
and alternate setting such as in an 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99213) provided on July 8, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that the service at issue should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $45 
copayment for a Medicare covered visit with a specialist.  
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the 
Physician/Practitioner services 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 
an office visit (99213) provided on July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 0037U provided on January 10, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by 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. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on November 30, 2021. This means there is no documentation to support the 
services provided on the billed date of service. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services coded 0037U provided on January 10, 2022.