Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge management (99238) provided September 
30, 2021. 
 
You asked the Plan to pay for the hospital discharge management. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the code billed is not payable on this date of 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 99238 is Hospital Discharge Day management, 30 
minutes or less. 
 
We find that CPT code 99238 is not supported in the medical record. Specifically, payment was already made 
for CPT 99239 (hospital discharge day management, 30 minutes or more) on the same date of service.  
 
 Based on this information, we decided that Medicare rules for coverage of the hospital discharge management 
have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge 
management (99238) provided September 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the neck and 
chest. 
 
You asked the Plan to pre-approve a CT scan of the neck and chest. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the neck and chest. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the last CT of the 
neck was negative on November 17, 2021. No change in symptoms or physical exam. Medical necessity has 
not been established. The CT of the chest revealed no mass. There is a 5 mm nodule for which a 1-year 
surveillance has been suggested. Absent any palpable mass etc. the medical necessity of CT of the chest has not 
been established. 
 
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 neck and chest have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) scan of the neck and chest.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home physical therapy visits. 
 
You asked the Plan to pre-approve 4 home physical therapy visits. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 4 home physical therapy visits. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that further skilled therapy services are required to effectively 
provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a 
maintenance program to maintain your level of function and/or prevent deterioration. Records provided to this 
reviewer only include nursing notes with regard to care of the coccyx wound. No notes from physical therapy 
were provided documenting a need for the requested four additional physical therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 home physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 4 home physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant to surgery services provided on April 6, 2021. 
 
You asked the Plan to pay for the assistant to surgery services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says code 11044 has a surgery 
indicator of "1" which does not allow for assistant surgeon payment. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 11044. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
assistant to surgery services have not been met. Therefore, we decided that the Plan does not have to pay for 
the assistant to surgery services provided on April 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xigduo XR. 
 
You asked the Plan to pre-approve Xigduo XR. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xigduo XR.  
 
Benefits for Xigduo XR may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
myalgia, mental status changes, and urinary tract infection. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program.  While you have 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 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI, a special kind of picture of your hip, knee or ankle 
without contrast (dye) (CPT code 73721). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. 
The Plan says the enrollee's records did not include a detailed history that shows this study is needed. 
 
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 the MRI. Our physician reviewer found 
the enrollee is being seen by an orthopedic specialist and whole records have not been enclosed for review. It 
may well be that the enrollee qualifies for MRI based upon the enrollee's evaluation and treatment by their 
orthopedic doctor, but those records have not been forwarded. Without such records the medical necessity of 
MRI of the left knee cannot be established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI, a special kind of picture of your hip, knee or ankle without contrast (dye) (CPT code 
73721).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistance services (25606) provided September 30, 
2021. 
 
You asked the Plan to pay for the surgical assistance services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this service is not eligible for payment for surgical 
assistants. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 25606. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
surgical assistance services have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical assistance services (25606) provided September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve astigmatism correcting function of intraocular lens. 
 
You asked the Plan to pre-approve astigmatism correcting function of intraocular lens. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been 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 pre-approve astigmatism correcting function of 
intraocular lens. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found per NCD 80.7, the correction of common refractive 
errors (astigmatism is a type of refractive error) by eyeglasses, contact lenses or other prosthetic devices is 
specifically excluded from coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of astigmatism correcting function of intraocular lens have not been met. 
Therefore, we decided that the Plan does not have to pre-approve astigmatism correcting function of intraocular 
lens.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan provided on December 22, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the duplex scan provided by an OON provider. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided 
were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 duplex scan provided on December 22, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit services (99212, 1159F, 1160F, 3077F, 3080F, and 
1125F) provided on September 2, 2021. 
 
You asked the Plan to pay for the office visit services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has failed to 
take any of the actions listed above that would meet their obligations regarding coordination of benefits. The 
Plan has not sent the bill for these items to the primary insurer. The Plan has not directed the provider to send 
the bill to the primary insurer. The Plan has not made provisional payment for these items with the option of 
submitting the bill for reimbursement to the primary insurer. The Plan has provided no documentation of any of 
these efforts that would have satisfied this burden. Therefore, we decided that the Plan has to pay for the office 
visit services (99212, 1159F, 1160F, 3077F, 3080F, and 1125F) provided on September 2, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's inpatient hospital care provided from April 8, 2021, through 
May 21, 2021 at the in-network benefit level. 
 
You asked the Plan to pay for the physician's inpatient hospital care. You say that the claims should be paid  
in-network based on the member's inpatient status. The Plan denied your request. The Plan says that the claims 
processed correctly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the Plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The enrollee was referred for the physician's inpatient hospital care by a contract hospital. The file does not 
show that the Plan provided notice that the physician's inpatient hospital care would not be covered. Under 
Medicare rules, this means the physician's inpatient hospital care is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for physician's inpatient hospital care provided from 
April 8, 2021, through May 21, 2021 at the in-network benefit level. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of the Optimizer Smart 
permanent cardiac contractility modulation system. 
 
You asked the Plan to pre-approve insertion or replacement of the Optimizer Smart permanent cardiac 
contractility modulation system. You say that the services are necessary. The Plan denied your request. The 
Plan says based on the documentation provided, coverage criteria has not been 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 pre-approve insertion or replacement of the 
Optimizer Smart permanent cardiac contractility modulation system. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found while the clinical studies led to FDA approval in 2019, cardiac contractility modulation (CCM) remains 
the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the CCM system is not medically necessary in this 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion or replacement of the Optimizer Smart permanent cardiac contractility 
modulation system have not been met. Therefore, we decided that the Plan does not have to pre-approve 
insertion or replacement of the Optimizer Smart permanent cardiac contractility modulation system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle libre 2. 
 
You asked the Plan to pre-approve a Freestyle libre 2. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle libre 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a face down positioning pillow. 
 
You asked the Plan to pre-approve a face down positioning pillow. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a face down positioning pillow.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on June 8, 2021.