Persius/hicric huggingface dataset:
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital with cellulitis of the foot and had a below the knee amputation. He is now medically stable with no 
complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While he has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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 anesthesia (99100) provided on August 17, 2021 
 
You asked the Plan to pay for the anesthesia (99100). The Plan denied your request. The Plan says bundled 
services are not eligible for separate payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on August 17, 
2021
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided from July 13, 2021, 
through August 5, 2021, by a licensed professional counselor (LPC). 
 
You asked the Plan to pay for the LPC services. You say that you have showed proof that the enrollee is 
licensed as a therapist. You say this means the services should be covered. The Plan denied your request. The 
Plan says the provider from whom you obtained these services is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program as they are not an eligible type of provider. Therefore, we decided that the Plan does not have to pay 
for the psychotherapy services provided from July 13, 2021, through August 5, 2021, by a licensed professional 
counselor (LPC).
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 you believe that you require IRF care. The Plan 
denied your request. The Plan says Medicare IRF criteria have not been met. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for coronary artery bypass grafting. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the patient has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided during a sleeve 
gastrectomy procedure on October 11, 2021, billed with code 49905-AS. 
 
You asked the Plan to pay for the surgical assistant services as billed. You say that this was billed correctly. 
The Plan denied your request. The Plan says the report does not support the use of code 49905. 
 
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 49905 is Omental flap, intra-abdominal (List separately 
in addition to code for primary procedure). 
 
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 surgical assistant services as billed. Our reviewer says 
that this code is not supported by the records. Our reviewer found the operative report does not include 
sufficient documentation to confirm this procedure has been performed. To cite the operative report "Pedical flap of the omentum was now mobilized and sutured to the cut edge of the stomach for purposes of 
hemostasis. This was accomplished with a running absorbable 3-0 Sirafix suture. This was begun at the GE 
junction and extended down to the end of the staple line on the antrum."  
 
However, the code billed is described thus: "An upper abdominal transverse or midline incision is made.  A 
laparatomy and manual exploration of the abdomin cavity is done first and the omentum and transerve colon 
are delivered from the cavity.  The omentum is dissected from the transverse colon from left to right and small 
vessels are ligated.  When completely separated from the transerve colon, the omentum is dissected from the 
stomach with careful clamping, division, and ligation of vessels.  The omentum is fully mobilized and pedicled 
on the right or left gastroepiploic vessel, depending on the purpose. Our coder decided that this definition was 
not documented in the report. 
 
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 surgical assistant services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical assistant services provided during a sleeve 
gastrectomy procedure on October 11, 2021, billed with code 49905-AS.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD) surgery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD is covered for beneficiaries enrolled in an 
approved clinical study. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested PILD surgery is 
considered experimental in nature, as more research is needed to support its safety and effectiveness. The 
procedure is therefore not reasonable or medically necessary at this time. The file does not show that the 
procedure is being requested as part of a Medicare-approved clinical study. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve percutaneous image-guided lumbar decompression (PILD) surgery.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy, 60 minutes with patient (CPT code 90837) 
provided on November 10, 2021, through November 11, 2021. 
 
You asked the Plan to pay for the service. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 service have not been met. Evaluation and management by 
psychologists is covered by Medicare under the following conditions: "Provider must attempt to consult the 
attending or primary care physician about the services furnished and document the consent or declination date 
to consultations, and the date of consultations in the patients medical record. If consultation with the 
attending or primary care physician is unsuccessful, document in the patients medical chart with the date and 
manner of notification to the physician does not consent If attempts to consult directly with the physician are 
not successful, to notify the physician, within a reasonable time, that he or she is furnishing services to the 
beneficiary. There is no referring physician listed on the claim. Therefore, we decided that the Plan does not 
have to pay for psychotherapy, 60 minutes with patient (CPT code 90837) provided on November 10, 2021, 
through November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx genetic testing (81479) provided to the enrollee 
on August 2, 2021. 
 
You asked the Plan to pay for SelectMDx genetic testing (81479). You say that this testing was medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. 
 
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 pay for SelectMDx 
genetic testing (81479). Our physician reviewer found SelectMDx genetic testing (81479) is not medically 
reasonable and necessary. The scientific evidence is insufficient to determine the effects of this testing on 
health outcomes. Longer term follow-up of the cohorts is needed to determine whether clinically significant 
prostate cancers were ultimately detected in those that had low risk scores with this testing. In addition, MRI 
scanning has been shown to be the most accurate test to determine the presence of significant prostate cancer.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SelectMDx genetic testing (81479) have not been met. Therefore, we decided 
that the Plan does not have to pay for SelectMDx genetic testing (81479) provided to the enrollee on August 2, 
2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Guardian sensors for an adjunctive continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the sensors of the adjunctive CGM. You say that these sensors are necessary 
for the functioning of the enrollee's insulin pump and in order to monitor blood sugar levels. The Plan denied 
your request. The Plan says that CGMs coded as A9276 are considered precautionary and are noncovered. 
 
The Plan must follow Medicare rules. The rules say that CGMs may be considered reasonable and necessary 
for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
In this case, the documentation submitted provides evidence that the enrollee tests multiple times per day and 
receives at least 3 insulin infusions from the external pump. These doses of insulin are adjusted based on the 
readings from the CGM. It also shows that the enrollee is seen by the provider regularly to ensure compliance 
with the criteria for coverage. Although the code A9276 is inappropriate for the items being requested, the 
criteria for these items are met, and this would be payable when billed with code A4238. Based on this information, we find that coverage criteria for the CGM sensors being requested have been met. Therefore, we 
decided that the Plan has to pre-approve Guardian sensors for an adjunctive continuous glucose monitor 
(CGM).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the hip x-ray (CPT code 73502) provided 
on August 9, 2021, by an in-network provider. 
 You asked the Plan to waive the deductible for the hip x-ray. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2021 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
For service 73502 the provider billed the plan in the amount of $210.80 and the allowed amount is $36.51. 
Since you had not reached your deductible, the full amount of $36.51 was applied correctly as your liability. 
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 deductible for the hip x-ray (CPT code 73502) provided on August 9, 2021, 
by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME (CPT code(s): A6023-A1, A6213-A1, A6199-A1, 
and A4450-AW-A1) provided on October 13, 2021. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
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 DME have not been met. CPT code(s): A6023-A1, A6213-A1, 
A6199-A1, and A4450-AW-A1, remain not supported. The documentation submitted did not include an 
itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of 
service. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to 
contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for the 
DME (CPT code(s): A6023-A1, A6213-A1, A6199-A1, and A4450-AW-A1) provided on October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, eye, for detection of foreign 
body (CPT code 70030-26) provided on September 21, 2021. 
 
You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the procedure code is inconsistent with the modifier used. The Plan states this 
should be billed with the appropriate code for these services. 
 
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 service have not been met. The provider submitted multiple 
corrected claims with modifier 26 and 76, in an attempt to reprocess the claim, it was determined that modifier 
LT or RT needed to be billed to indicate which eye the services were rendered on. Because the incorrect 
modifiers were billed, we have decided to uphold the original determination. Therefore, we decided that the Plan does not have to pay for the radiologic examination, eye, for detection of foreign body (CPT code 70030-
26) provided on September 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interventional radiology services provided on August 12, 
2021, billed with code 75736-59. 
 
You asked the Plan to pay for the services as billed. You say that it is felt that this was billed correctly. The 
Plan denied your request. The Plan says this code is not separately payable in spite of the use of modifier -59. 
 
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 75736 is a column II code to column I code 37244; however, 75736 
was billed with a modifier.  
 
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 as billed. Our reviewer says that the 
documentation does not support that modifier -59 is clinically appropriate in this case to bypass the edit. Our 
reviewer found the operative report describes a revascularization with radiological supervision. The 
revascularization code reported includes radiological supervision. Per CPT guidelines "Lower extremity 
endovascular revascularization codes all include the work of accessing and selectively catheterizing the vessel, 
traversing the lesion, radiological supervision and interpretation directly related to the interventions(s) 
performed". In this case, modifier -59 is not supported. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the interventional radiology services provided on August 12, 2021, billed with code 
75736-59.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not met. 
 
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 
complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ophthalmology visit you had on 
November 23, 2021. 
 
You asked the Plan to reduce the copayment for the ophthalmology visit. You say that this was a routine, not 
diagnostic, visit, so your copayment should only be $10. The Plan denied your request. The Plan says this was 
a diagnostic visit, so you were charged this copayment 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 $40 
copayment for Medicare-covered eye exams.  
 
You have been asked to pay a $40 copayment for the ophthalmology visit. We looked at the records in this case 
to determine the type of visit you had.  According to the records, during this visit you were diagnosed with 
central serous chorioretinopathy. This is a medical condition and not part of a routine exam.  That is why this 
visit falls within the Medicare-covered eye exams 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 reduce the 
copayment for the ophthalmology visit you had on November 23, 2021.