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

 
We decided that the Plan does not have to pre-approve magnetic resonance (eg, proton) imaging (MRI), spinal 
canal and contents, lumbar (72148). 
 
You asked the Plan to pre-approve an MRI. You say that the MRI is medically necessary. The Plan denied your 
request. The Plan says the MRI is 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 an MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the provided documentation does not clearly 
describe the justification for this advanced imaging. The reviewer found there was no report of having failed 
conservative treatments for the low back pain including physical therapy (PT), non-steroidal anti-inflammatory 
drugs (NSAIDs), and there were no provided objective findings revealing a red flag diagnosis to support early 
imaging. Therefore, this request for MRI will be considered 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 an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, lumbar (72148).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal cord stimulator replacement. 
 
You asked the Plan to pre-approve spinal cord stimulator replacement. You say that you are unable to hear the 
beeps on the stimulator to know when to replace the battery. The Plan denied your request. The Plan says the enrollee's spinal cord stimulator was placed less than 6 months ago. The Plan says that the enrollee's device 
also has visual light indicators when the device is charging. 
 
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 spinal cord stimulator replacement. Our 
reviewer says that spinal cord stimulator replacement is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is being treated for radiculopathy of the lumbar region. 
She presented with pain at 7/10. She is having an easier time getting around when the stimulator is working. 
She is deaf and so cannot hear the beeps when she is trying to recharge the batter. She would like to put in a 
Boston non-rechargeable. The exam reveals no signs of infection. She does have some mild tenderness over the 
battery site. However, detailed documentation is not evident regarding the spinal cord stimulator itself 
malfunctioning. The documentation does not detail any adjustments having been trialed prior to the request for 
revision. The documentation does indicate the device not only has beeps for the charging, but also has lights 
that can be utilized. The medical necessity for revision has not been met. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator replacement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve spinal cord stimulator replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider at an in-network benefit level. 
 
You asked the Plan to pre-approve an office visit. You say that that you would like to continue to receive care 
with your primary doctor and other specialists on your Plan at the requested cancer center. The Plan denied 
your request. The Plan says you are being denied the in-network benefit level with an OON provider. There are 
specialists with the expertise you need who are in your insurance network, who can see you in the near future. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that if you use an out-of-network provider, your share of the costs for your covered services may be 
higher. 
 
 
 The requested provider in this case is not a network provider with the Plan. The records show you are enrolled 
in a plan where you can see either a network provider or an OON provider. The EOC explains to see a provider 
at an in-network benefit level, the Plan has network providers available who can provide the items/services at 
issue in this appeal. The EOC also explains that if you choose to see an OON provider, your out-of-pocket 
costs may be higher. Therefore, we decided that the Plan does not have to pre-approve an office visit to be 
provided by an out-of-network (OON) provider at an in-network benefit level.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic laboratory services (88312, 88305) provided on 
February 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic laboratory services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as 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 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 diagnostic laboratory services (88312, 88305) 
provided on February 11, 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 spinal manipulation services and other billed codes 
provided by an out-of-network (OON) chiropractor from January 5, 2022, through January 14, 2022. 
 
You asked the Plan to pay for the chiropractor-rendered OON services. You say that the enrollee is entitled to 
coverage of all Medicare-covered services. The Plan denied your request. The Plan says most of the denied 
services are not covered by Medicare when provided by a chiropractor. As for code 98940, this is Medicare-
covered but was provided OON without authorization. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules also allow Plans to restrict enrollees to 
network providers.  
 The records show that the services at issue are not manual manipulation of the spine. As for the spinal 
manipulation, this was provided OON without authorization. There were network providers able to render this 
care. Therefore, we decided that the Plan does not have to pay for the spinal manipulation services and other 
billed codes provided by an out-of-network (OON) chiropractor from January 5, 2022, through January 14, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 29, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you have provided the medical records and 
would like the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved 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 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 December 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on September 21, 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 procedure code 83789 is 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. In this case, we have confirmed that code 83789 is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the mass spectrometry rendered on September 21, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 95819 billed for date of service December 9, 2021. 
 
You asked the Plan to pay for procedure code 95819. You say that this code is supported by the medical record. 
The Plan denied your request. The Plan says that insufficient documentation was provided to corroborate this 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 95819 is electroencephalogram; including recording awake and asleep. 
 
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 procedure code 95819. Our reviewer says that procedure 
code 95819 is supported in the medical record. Our reviewer found the medical records supplied with the 
appeal request provide a breakdown of procedure code 95819. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95819 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 95819 billed for date of service December 9, 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 laboratory services rendered on January 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows that the services were not performed for a hospital inpatient. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric services. You say that the records provided support the 
need for continued inpatient psychiatric care. The Plan denied your request. The Plan says the request is not 
medically necessary because the records show that the enrollee's condition has improved, and they are no 
longer a threat to themselves or others. The Plan says that care could be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on June 3, 2022, with Major Neurocognitive 
Disorder, Unspecified with Behavioral Disturbance and Schizoaffective Disorder Type. Based upon review the 
records provided it was not expected this enrollee would improve in a reasonable period of time beyond the 
dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations 
and was without aggressive behaviors while not showing any acute threats of safety. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care beyond the dates in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the patients condition or for the purpose 
of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on March 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 procedure code 99291 is not supported. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically. there is no documentation of 
the first 30-74 minutes of critical care services spent on the enrollee. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the critical care services rendered on March 26, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you already have the monitor, but you 
have run out of sensors. You also say that the CGM has been more effective and has helped to control your 
blood sugar, especially at night. The Plan denied your request. The Plan says you do not meet prior 
authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM) and supplies (K0553).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided on 
February 8, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic service. You say that your physician's are hospital based. Your 
association has not opportunity to pre-authorize imaging studies. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 radiologic examination, chest (71045) 
provided on February 8, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on February 14, 2022 by an 
out-of-network (OON) provider. 
 
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 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 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 telehealth services provided on February 14, 
2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found based on the 
medical records provided there is no documentation that the enrollee requires the services on an inpatient basis, 
only in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 2, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 2, 2021.