Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 3, 
2022. 
 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 August 3, 2022.
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 services are necessary for the enrollee. 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation indicates that the enrollee is functioning at a level 
routinely addressed post-acute at levels of care other than an IRF. The reviewer found the enrollee does not 
require intensive rehabilitation and has reduced capacity to participate in or benefit from intensive 
rehabilitation. The enrollee does not require frequent physiatry oversight. Therefore, the reviewer found that 
the requested IRF care is not medically necessary in this case. 
 
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 pre-approve a panniculectomy. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has had significant weight 
loss after bariatric surgery, resulting in a pannus. There is no documentation of intertrigo upon examination. 
There is no documentation of a trial and failure of intertrigo refractory to conservative medical treatment. There 
are no documented functional impairments resulting from the pannus. The panniculectomy is therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a panniculectomy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 27, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat trial of a neurostimulator device (63650). 
 
You asked the Plan to pre-approve a repeat trial. You say that the enrollee only had 20% relief from the first 
trial. You also say that you would like to do a new trial with a different manufacturer. The Plan denied your 
request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat trial. Our reviewer says that the 
requested repeat trial for a neurostimulator device is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation indicates that the enrollee failed the initial 
trial. The reviewer found that there are no guidelines that support a second trial. Therefore, the reviewer found 
that a repeat trial is not medically necessary in this case. 
 
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 repeat trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat trial of a neurostimulator device (63650).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on February 25, 2022, to 
March 16, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted for these 
services. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
February 25, 2022, to March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 18, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says that 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 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 provided on May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an OON provider. 
 
You asked the Plan to pre-approve the office visits. You say that you cannot go to the provider as you don't feel 
comfortable receiving care there. The Plan denied your request. The Plan says there are in-network facilities 
and providers that can provide this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits to be provided by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 15, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 laboratory services provided on October 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 11, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
member was enrolled in hospice on this date of service. Traditional Medicare is the primary payer. 
 
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 subsequent nursing facility care provided on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic mattress. 
 
You asked the Plan to pre-approve a therapeutic mattress. You say that you requested a quality mattress bed 
due to your chronic neck and back pain. The Plan denied your request. The Plan says the therapeutic mattress 
(commercial type of mattress) is not covered because it is not medical in nature and is regularly and primarily 
used by persons who do not have a specific medical need for them; therefore, this request has been denied. 
 
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 a therapeutic mattress have not been met. The rules say that 
mattresses are covered only where hospital bed is medically necessary. You do not have a specific medical 
need for the mattress or hospital bed. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the air purifier. 
 
You asked the Plan to pre-approve the air purifier. You say that you have trouble breathing through one nostril. 
The Plan denied your request. The Plan says the air purifier is mostly for convenience purposes. 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 the air purifier.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires the level of care available at the 
IRF. The Plan denied your request. The Plan says IRF care is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain her functional status.  
 
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 physician pathology services provided on December 30, 
2021, billed with codes 88341, 88342, and 88360. 
 
You asked the Plan to pay for the pathology services. You say that this claim should be paid as billed. The Plan 
denied your request. The Plan says these codes can only be paid if billed with modifier -26. 
 
The Plan must follow Medicare rules. Medicare rules say that the TC of physician pathology services for 
services rendered to a hospital inpatient or outpatient.  
 
 We looked at the file and Medicare rules. The documentation supports that the enrollee was inpatient when this 
sample was taken. As such, the TC cannot be paid. Based on this information, we decided that Medicare rules 
for coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to 
pay for the physician pathology services provided on December 30, 2021, billed with codes 88341, 88342, and 
88360.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says Original Medicare 
must be billed for this service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on April 17, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided 
on April 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen and pelvis 
services. 
 
You asked the Plan to pre-approve a CT of the abdomen and pelvis. You say that the records provided support 
the need for the requested CT scan. The Plan denied your request. The Plan says the provider has not told them 
why a scan of the abdomen is needed. 
 
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 of the abdomen and pelvis. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found there are no 
abdominal complaints.  Symptoms include chest pain radiating to neck and left arm. The request for CT of the 
abdomen and pelvis is not supported by the records. 
 
 
 
 
 
 
 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 of the abdomen and pelvis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve computed tomography (CT) of the abdomen and pelvis services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard test. 
 
You asked the Plan to pre-approve a Cologuard test. You say that you would like the Cologuard test mailed out 
because the doctor ordered it, and you feel it is necessary for the enrollee's health. The Plan denied your 
request. The Plan says Medicare NCD criteria are not met, as exceeds the age limit, and does not fall within the 
age range that is eligible for coverage. The Plan also says that this test was not ordered as a preventative or 
screening, but rather as a diagnostic test for the enrollee's unexplained anemia, and medical necessity has not 
been established. 
 
The Plan must follow Medicare rules. Medicare rules say that The Cologuard test is covered once every three 
years for Medicare beneficiaries that meet all of the criteria listed in the Medicare rules section of this letter. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Cologuard test have not been met. Specifically, the enrollee is currently 88 years old, exceeding 
the age range for coverage of this test. Therefore, we decided that the Plan does not have to pre-approve a 
Cologuard test.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for additional physical therapy sessions 
provided by a participating provider. 
 
You asked the Plan to waive the copayment for physical therapy. You say that physical therapy helps manage 
your chronic condition. The Plan denied your request. The Plan says additional physical therapy is 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 waive the copayment for physical therapy. Our 
reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the records document the enrollee has been educated 
on her condition, meditation, self-care and a home exercise program with which she is compliant. Further 
utilization of the home exercise program appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to waive the copayment for additional physical therapy sessions provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit by the Plan or by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate for you, it does not fall into a covered benefit category and cannot be 
paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve 
compression stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for non-emergency transportation. 
 
You asked the Plan to waive the copayment for non-emergency transportation. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the enrollee 
has used thirty (30) one-way trips this year (2022). Additional trips in excess of thirty (30) one-way trips are 
non-covered by the health plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to waive the copayment for are ambulance transport services to a doctors 
office. Therefore, we decided that the Plan does not have to waive the copayment for non-emergency 
transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings (A6530 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings (A6530 x 2).