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

 
We decided that the Plan does not have to pay for the services (92604-LT, 92604-RT) provided on April 29, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT codes 92604-LT and 92604-RT is not supported in the medical record. 
Specifically, code 92604 is assigned a bilateral surgery indicator of 0. This means that code 92604 should not 
be billed with modifiers -LT and -RT. 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 services 
(92604-LT, 92604-RT) provided on April 29, 2022.
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 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 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 are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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 subsequent nursing facility care (99309) provided on 
February 28, 2022, by the out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you were contacted by the facility to treat 
the enrollee. You say that you depend on the facility to verify eligibility and obtain proper authorization. You 
also say that the medically necessary services were rendered to the enrollee in good faith. The Plan denied your 
request. The Plan says authorization was not obtained before the services were rendered to the enrollee. 
 
Medicare rules say may require enrollees to obtain authorization before receiving services. 
 
We looked at your request, the file and rules. Based on this information we have determined that criteria for 
coverage of the physician services have not been met. Specifically, the documentation does not support that 
prior authorization was obtained by the provider prior to the services being rendered. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on February 28, 
2022, by the out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy (97124), ultrasound therapy (97035), 
mechanical traction therapy (97012), and the neuromuscular reeducation (97112) rendered by the out-of-
network (OON) provider from January 10, 2022, through January 24, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as they were 
rendered by an out-of-network provider, without prior authorization. 
  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says that the Point of Service (POS) option 
allows enrollees to obtain services from an out-of-network provider with a referral from a primary care 
physician.  
 
Your organization is not a network provider with the Plan. A referral was not issued by the enrollees primary 
care physician for the services provided in this case. The Plan contract states that if an enrollee does not get a 
referral for services provided by an out-of-network provider, they will have to pay the full cost of any services 
received. The Plan did not pre-approve these services. 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 the massage therapy 
(97124), ultrasound therapy (97035), mechanical traction therapy (97012), and the neuromuscular reeducation 
(97112) rendered by the out-of-network (OON) provider from January 10, 2022, through January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection, anesthetic agent and/or steroid, 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve the epidural steroid injection. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the criteria has not 
been met as the records show that the enrollee just had an epidural steroid injection on July 1, 2022 in the same 
location. A second shot, at the same location cannot be approved at this time. 
 
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 epidural steroid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested epidural is a transforaminal left L3-4 epidural per 
documentation. The enrollee has had a left L4-5 transforaminal injection on 7/1/22. The guidelines states that a 
epidural will be considered medically reasonable and necessary if the patient has history, physical exam and 
concordant radiological image based diagnostic testing that supports lumbar radiculopathy, radicular pain 
and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative 
disc disease, producing foraminal or central spinal stenosis or post-laminectomy syndrome, or  acute herpes 
zoster associated pain. There is no herpes zoster pain, post laminectomy pain. The imaging study does not 
support concordant findings in the L3-4 distribution. The motor and sensory exam are not consistent with an 
L3-4 myotomal and dermatomal distribution. For these reasons this request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the injection, anesthetic agent and/or steroid, transforaminal epidural, with 
imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on December 29, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
documentation does not support the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records from the treating 
physician to determine whether the rules for coverage have been met. Therefore, we decided that the Plan does 
not have to pay for the gene panel testing provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field examination (92083) and scanning 
computerized ophthalmic diagnostic imaging (92134) provided on January 27, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for a visual field examination and scanning computerized ophthalmic diagnostic 
imaging. You say that the services were necessary, and an authorization was sent. The Plan denied your 
request. The Plan says the provider is out-of-network, and no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a visual field examination (92083) and scanning 
computerized ophthalmic diagnostic imaging (92134) provided on January 27, 2022, by an out-of-network 
(OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that continued therapy is needed to maintain 
functional status. The Plan denied your request. The Plan says that therapy services 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 therapy visits. 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 that the enrollee has been instructed in a home exercise 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 therapy visits. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 18 physical therapy visits.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (25500) provided on June 11, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 25500 is "Closed treatment of radial shaft fracture; 
without manipulation". 
 
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. Our reviewer says that the use of code 25500 is 
not supported by the records provided. Our reviewer found that the procedure report documents "Definitive 
Fracture Care Pain control, Sling, Splint, Follow up > 24 hrs, Performed by me nl, Condition improved, 
Tolerated procedure well, Patient stable". In this case, "without manipulation" per CPT code description cannot 
be verified. Also, modifier -54 cannot be verified in this case. 
 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 have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (25500) provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Botox injection. 
 
You asked the Plan to pre-approve a Botox injection. You say that a Botox injection is medically necessary. 
The Plan denied your request. The Plan says Botox injections do 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 a Botox injection. Our reviewer says 
that a Botox injection is not medically necessary. Our physician reviewer found that based on the medical 
records provided and the Medicare-approved major drug compendia there is no documentation that the Botox 
at issue in this case meets Medicare criteria for medically reasonable and necessary, safe and effective.  
Treatment of a hernia area pre-operatively to aid in surgical closure is not a medically accepted indication for 
use of Botox as defined by Medicare criteria. 
 
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 Botox injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Botox injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home healthcare services provided on November 20, 
2021. 
 
You asked the Plan to pay for the home healthcare services. You say that you would like this claim to be 
reconsidered and processed for payment. The Plan denied your request. The Plan says the non-contracted 
provider did not submit the RAP claim for services for this date of service until February 4, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home healthcare services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home healthcare services provided on November 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services provided on December 30, 
2021. 
 
You asked the Plan to pay for the ambulance transportation services. You say that the enrollee was transported 
from a nursing home to a Specialty Care Center for a higher level of care. You say that, as a result, there is no 
other modifier that you can use for this type of ambulance transportation. The Plan denied your request. The 
Plan says an incorrect modifier was used when billing the services in dispute. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT/HCPCS codes and modifiers. 
 
We find that the modifier attached to the ambulance service in dispute is not supported in the medical record. 
Specifically, the records show that the enrollee was transported from a SNF to an inpatient acute rehabilitation 
hospital. This means that the appropriate modifier would be "NH." However, the services were billed with a 
modifier of "NN." Based on this information, we decided that Medicare rules for coverage of the ambulance 
transportation services have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance transportation services provided on December 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex (J1561). 
 
You asked the Plan to pre-approve Gamunex. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the requested drug is not covered for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Gamunex. Our reviewer says that 
Gamunex is not medically necessary. Our physician reviewer found Gamunex is not Food and Drug 
Administration-approved for any of enrollees diagnoses. The reviewer found that the provided medical records 
do not document immunodeficiency on laboratory testing or any other medically accepted diagnosis for use of 
Gamunex. Therefore, the reviewer found that the requested drug is not medically necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gamunex (J1561).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that continued SNF care is medically necessary. The 
Plan denied your request. The Plan says you no longer require skilled services and the continuation of SNF is 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interspinous spacers (22869, 22870). 
 
You asked the Plan to pre-approve insertion of interspinous spacers. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules have 
not been met because the requested services are experimental/investigational. 
 
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 of interspinous spacers. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that interspinous spacers are experimental. More research is needed to 
demonstrate the safety and effectiveness of the requested services. 
 
 
  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 of interspinous spacers have not been met. Therefore, we decided that 
the Plan does not have to pre-approve insertion of interspinous spacers (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (37253) provided on December 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 37253 is "Intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (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 services. Our reviewer says that the use of code 37253 is 
not supported by the records provided. Our reviewer found that the procedural report does not include 
documentation of an intravascular ultrasound with additional noncoronary vessel. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (37253) provided on December 15, 2021.