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

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested inpatient psychiatric 
care is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for 
inpatient psychiatric care have not been met. 
 
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 care. Our reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician reviewer 
found that you do not meet the criteria for continued acute inpatient mental health treatment as you were not 
shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and 
were cooperative/compliant with treatment. 
 
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 care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One injections for the shoulder. 
 
You asked the Plan to pre-approve the Synvisc-One shoulder injections. You say that you have had a good 
response to this treatment for your knee pain. You feel that it should be allowed to treat your shoulder as well. 
The Plan denied your request. The Plan says this is not FDA-approved for your condition. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and 
effective and otherwise reasonable and necessary. The rules also say that viscosupplementation has therapeutic 
benefits for shoulder arthritis, when certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Synvisc-One shoulder injections. 
Our reviewer says that the requested treatment is not medically reasonable and necessary in this case. 
 Our physician reviewer found he record indicates that the enrollee has a diagnosis of osteoarthritis of the 
shoulder. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. Although the local Medicare contractor does provide 
coverage for this treatment for shoulder arthritis, the record provided does not indicate that the enrollee has 
failed conservative non-pharmacologic treatments or simple analgesics for the treatment of the noted condition. 
The elements of the coverage criteria are not satisfied.  
 
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 Synvisc-One shoulder injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Synvisc-One injections for the shoulder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you have multiple sclerosis and 
weakness on the left side. This would make transferring from the wheelchair to the commode, bed and car 
much easier. It would make you more independent and able to transfer on your own. The Plan denied your 
request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) continuous recording 
(95700) and EEG without video (95708) provided from August 24, 2021, to August 25, 2021 by an out-of-
network (OON) provider. 
 You asked the Plan to pay for the EEG continuous recording and EEG without video. You say that the services 
provided were medically necessary. The Plan denied your request. The Plan says these services were performed 
by an OON provider. The Plan also says that in-network providers were available. 
 
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 electroencephalogram (EEG) continuous 
recording (95700) and EEG without video (95708) provided from August 24, 2021, to August 25, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on November 8, 2021. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says the 
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. There was no documentation of contact in the patient record. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the record does not include documentation 
of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on 
November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy (97802) provided on June 8, 
2021. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you would like reconsideration 
because the services provided were medically necessary. The Plan denied your request. The Plan says medical 
nutrition therapy (MNT) is covered by Medicare only for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy (97802) provided on June 8, 2021.
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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for myocardial infarction, coronary artery bypass grafting and congestive heart failure. Medical problems are stable. There are no complex nursing 
or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 
14, 2021. 
 
You asked the Plan to pay for the dental service. You say that this service was necessary. You say that you 
needed to find a different provider to perform the crown. You also say that this service should be covered. The 
Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says 
that the frequency limit has been exceeded. 
 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and limited oral evaluation is covered 
once per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited 
oral evaluation that you received on June 14, 2021. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140) provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) and laboratory 
services (80307, G0480) provided on November 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit and laboratory services. You say that this 
provider provides care at the direction of the attending physician and, in turn, requests reimbursement for 
services rendered to your member. The Plan denied your request. The Plan says after review, it was determined 
that there are no records of a referral from the member's primary care physician to the Plan prior to 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 a hospital outpatient clinic visit (G0463) and 
laboratory services (80307, G0480) provided on November 24, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external mobile cardiovascular telemetry with 
electrocardiographic recording (93229). 
 
You asked the Plan to pre-approve an external mobile cardiovascular telemetry with electrocardiographic 
recording. The Plan denied your request. The Plan says you have not had a Holter monitor and you have not 
used a cardiac event monitor. The Plan also says that a continuous heart monitor not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the detection, characterization and documentation of 
symptomatic transient or paroxysmal dysrhythmia when the frequency of the symptoms is limited and the use 
of a 24-hour ambulatory electrocardiography (ECG) is documented in the medical record to be unlikely to 
capture and record the dysrhythmia is considered medically reasonable and 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 external mobile cardiovascular 
telemetry with electrocardiographic recording. Our reviewer says that there is insufficient documentation to 
support the medical necessity for a mobile cardiac outpatient telemetry monitor in your clinical management. 
Our physician reviewer found you have a history documented short bursts of atrial tachycardia without 
syncope, near-syncope, chest pains or shortness of breath. Our reviewer found that the physician reports that 
you have had no symptoms of any irregular heartbeats. Our physician reviewer also found that as such, 
guidelines would not support a need for mobile cardiac outpatient telemetry monitoring in this 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 an external mobile cardiovascular telemetry with electrocardiographic recording 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an external mobile 
cardiovascular telemetry with electrocardiographic recording (93229).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 20, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable.  
 
 
 
 
 Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other 
payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 7, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 7, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound services provided to the enrollee December 8, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim must be submitted to Original Medicare first. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for wound services provided to the enrollee December 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an FDG Positron Emission Tomography (PET) scan. 
 
You asked the Plan to pre-approve an FDG PET scan. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 FDG PET scan. Our reviewer says 
that an FDG PET scan is not medically necessary. Our physician reviewer found that the Medicare NCD 
guidelines require a differential diagnosis of Alzheimer's disease (AD) vs. Frontotemporal disorders (FTD) in 
order to qualify for PET. Nowhere in the records is there a discussion of possible FTD as a potential 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 an FDG PET scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an FDG PET scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on September 28, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on 
September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cytopathology Procedures (88120) provided November 10, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that please reconsider paying this claim. 
Hematuria is indeed a valid diagnosis for this procedure, and it is the one the physician assigned to the charge. The Plan denied your request. The Plan says the diagnosis code does not substantiate the service. The provider 
did not bill as required by Medicare coding regulations. 
 
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 88120 is cytopathology, in situ hybridization (eg, fish), urinary tract 
specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual. 
 
We find that CPT code 88120 is not supported in the medical record. Specifically, the genetic testing was not 
ordered/approved by the ordering provider.  Based on this information, we decided that Medicare rules for coverage 
of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for 
Cytopathology Procedures (88120) provided November 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93318) provided on April 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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, we have confirmed that code 93318 
is a column II code to column I code 00567. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 services (93318) provided on April 13, 2021.