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

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (64555) and implantable neurostimulator, pulse generator any 
type (L8679). 
 
You asked the Plan to pre-approve a percutaneous implantation of neurostimulator electrode array; peripheral 
nerve and implantable neurostimulator, pulse generator any type. The Plan denied your request. The Plan says 
the implantable neurostimulator does not meet Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a percutaneous implantation of 
neurostimulator electrode array; peripheral nerve and implantable neurostimulator, pulse generator any type. 
Our reviewer says that the requested percutaneous implantation of neurostimulator electrode array; peripheral 
nerve and implantable neurostimulator, pulse generator any type is not considered medically reasonable and 
necessary. Our physician reviewer found this is considered an experimental/ investigational approach and is not 
part of standard clinical guidelines. Therefore, the request is deemed not medically reasonable or 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 a percutaneous implantation of neurostimulator electrode array; peripheral 
nerve and implantable neurostimulator, pulse generator any type have not been met. Therefore, we decided that 
the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral 
nerve (excludes sacral nerve) (64555) and implantable neurostimulator, pulse generator any type (L8679).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 16, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an office visit provided on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (83789) provided on August 23, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says when specimen 
validity testing is conducted as part of drug testing, it cannot be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing shall not separately bill the validity testing. 
 
We looked at the file and Medicare rules. The specimen validity testing in question was performed as part of 
drug testing. This service is not separately payable. 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 the 
lab services (83789) provided on August 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming (CPT code 33285). 
 
You asked the Plan to pre-approve the service. You say that offering the enrollee an implantable loop recorder 
(ILR) will allow for long-term monitoring of frequency and symptoms associated with arrhythmia. The Plan 
denied your request. The Plan says the enrollee's records do not show a diagnosis of stroke, syncope, structural 
heart disease, or suspected ventricular arrythmia and there is no documentation to support this would change 
management. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while the enrollee has a history of palpitations and suspected atrial fibrillation, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion, subcutaneous cardiac rhythm monitor, including programming (CPT code 
33285).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan, heart, without 
contrast material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT scan of the heart, without contrast material, with quantitative 
evaluation of coronary calcium. You say that the requested service is medically necessary. The Plan denied 
your request. The Plan says Medicare does not cover the requested service for screening purposes 
 
The Plan follows Medicare rules. Medicare rules say that you must meet certain criteria for the service to be 
covered as noted in the Medicare rules section of this letter. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the heart, without contrast 
material, with quantitative evaluation of coronary calcium. Our reviewer says that there is no documentation 
that the enrollee meets Medicare coverage criteria for the requested service. Our physician reviewer found 
provided records do not document that the enrollee has any of the covered indications or signs or symptoms or 
history listed for coverage of the requested test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the heart, without contrast material, with quantitative evaluation of 
coronary calcium have not been met. Therefore, we decided that the Plan does not have to pre-approve 
computed tomography (CT) scan, heart, without contrast material, with quantitative evaluation of coronary 
calcium (75571).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on December 22, 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 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 G0481. 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 December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
because you broke your hip and are unable to drive to your dialysis appointments. The Plan denied your 
request. The Plan says you have exhausted the yearly allowed trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The 25th trip and beyond is not a covered benefit. Your 2022 EOC states they provide twenty-four (24) one-way trips to plan-approved locations every 
year, provided by the network transportation provider. Therefore, your request exceeds your benefit. Therefore, 
we decided that the Plan does not have to pre-approve additional routine transportation trips.
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 enrollee is medically ready and requires a doctor 
on site. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 was admitted for sepsis and gastrointestinal bleeding. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advance care planning rendered on July 8, 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 99497 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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, there is no documentation of 
a discussion between the provider and patient, along with family members or surrogates, regarding end-of-life 
decisions. 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 advance care planning rendered on 
July 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupation therapy sessions provided by a 
participating provider. 
 
You asked the Plan to pre-approve occupational therapy. You say that additional occupation therapy sessions 
are medically necessary. The Plan denied your request. The Plan says additional OT sessions are not medically 
necessary. 
 
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 occupational therapy. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested remaining services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occupational therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional occupation therapy sessions provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are asking to be moved to another 
facility that offers more services. The Plan denied your request. The Plan says authorization denied because the 
LTACH is not medically necessary, and your care can be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available. 
The record shows there is no advantage in transferring to the LTACH. You can remain at the current ACH until 
such time no acute services are required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in TTV-VAPS-AE mode 
that could be delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
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 home ventilator. Our physician 
reviewer found there is documentation that you have chronic respiratory failure due to chronic obstructive 
pulmonary disease. There is no documentation that the ventilator at issue meets Medicare criteria for medically 
necessary and reasonable for you. As stated in the LCD: Respiratory Assist Devices (L33800): "Claims for 
ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be 
denied as not reasonable and necessary." Provided records do not document trial and failure of a BiPAP device 
with average volume assured pressure support - auto EPAP.  
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 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were admitted with hyponatremia and congestive heart failure with acute kidney 
injury. The record indicates that you still require acute care services before transitioning to a lower level of 
care. You continue to receive acute care services, and these have not been denied. The medical record does not 
indicate that you require services that you are not currently receiving but that would be available at the LTACH 
facility. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy services coded 31624 provided on June 23, 
2021. 
 
You asked the Plan to pay for the bronchoscopy services. You say that you would like the plan to reconsider 
their 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 31624 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with bronchial alveolar lavage. 
 
 We find that CPT code 31624 is not supported in the medical record. Specifically, the submitted medical 
records do not support that a bronchoscopy, rigid or flexible, including fluoroscopic guidance, when 
performed, with bronchial alveolar lavage was performed. Based on this information, we decided that Medicare 
rules for coverage of the bronchoscopy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the bronchoscopy services coded 31624 provided on June 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupation therapy sessions provided by a participating 
provider. 
 
You asked the Plan to pre-approve occupation therapy sessions. You say that additional OT sessions are 
medically necessary. The Plan denied your request. The Plan says additional OT sessions are not medically 
necessary. 
 
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 occupation therapy sessions. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the requested additional services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occupation therapy sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve occupation therapy sessions provided by a participating provider.