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

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service February 25, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service February 25, 2022, billed 
with code 99153.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the abdomen and pelvis (74177). 
 
You asked the Plan to pre-approve a CT of the abdomen and pelvis. You say that the enrollee has several 
disorders which make it difficult to do a comprehensive exam on them. You also say that you would like this 
test to be approved for coverage because the enrollee is unable to pinpoint where their pain is due to their 
limited abilities. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for 
coverage. 
 
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 a CT of the abdomen and pelvis is reasonable and necessary. Our physician reviewer found 
the enrollee has had a prior cholecystectomy, and a fibroscan which revealed mild steatosis and possible liver 
mass in right lobe.  The enrollee then had a CT of the abdomen and pelvis using 3 phase technique on February 
12, 2022 which showed no liver mass or other abnormality except for a fat containing umbilical hernia. Our 
reviewer found during an encounter August 30, 2022, the enrollee had a large difficult to reduce 4 centimeter 
umbilical hernia. Such a hernia, while shown to be fat containing on the prior CT is worrisome for 
strangulation due to its size, hardness and related to the enrollee's pain. Our physician reviewer also found that 
the liver needs no further workup in light of the CT from February 12, 2022, however, the umbilical hernia 
does, and for that reason the CT of the abdomen and pelvis is indicated and should be approved. 
 
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 has to pre-approve a computed tomography (CT) of the abdomen and pelvis (74177).  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for dialysis procedures provided on March 2, 2022, to March 30, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for dialysis procedures. You say that you have been providing life sustaining 
services to this patient and the absence of an authorization for these dates of service was inadvertent. You ask 
that the authorization requirements be waived, and that payment be made on these outstanding claims. The Plan 
denied your request. The Plan says the enrollee must receive care from a network provider. 
 
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 dialysis procedures provided on March 2, 2022, to 
March 30, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transit handles (K0108) and an expandable controller 
(E2377, E2313, E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve the transit handles and expandable controller. You say that the requested 
features are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met.  
The Plan follows Medicare rules. Medicare rules say that items for use outside the home are non-covered. 
Expandable controllers are covered when 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 transit handles and expandable 
controller. Our reviewer says that the requested features are not medically necessary. Our physician reviewer 
found the requested electrical accessories are not medically necessary as the member does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. The transit handles are for use outside the home and are non-covered 
 
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 transit handles and expandable controller have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transit handles (K0108) and an expandable controller 
(E2377, E2313, E2311) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prescription drug, Ondansetron. 
 
You asked the Plan to pre-approve a self-administered drug. You say that you disagree with the denial. The 
Plan denied your request. The Plan says The drug is also not being used as a full therapeutic replacement for IV 
anti-emetic drugs that would have been administered at the time of the chemotherapy treatment. The Plan also 
says the requested medication is not covered under the medical benefit. You do not have a pharmacy benefit 
with the plan. You have a drug plan which provides its own pharmacy benefits. 
 
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 a prescription drug, 
Ondansetron.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that the nursing home and their PCP is in another 
building, and you must take an ambulance to get there. The Plan denied your request. The Plan says when the 
enrollee becomes a member of our plan, the enrollee must choose a plan provider to be their primary care 
provider (PCP). The enrollees PCP is a physician, nurse practitioner, or physicians assistant who meets state 
requirements and is trained to give the enrollee general medical care. As we explain below, the enrollee will get 
their routine or general medical care from their PCP. The enrollees PCP will also coordinate referrals to other 
network providers such as specialists. 
 
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 visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Holter monitor for 2 weeks. 
 
You asked the Plan to pre-approve Holter monitor. You say that has had ongoing symptoms since reversing 
their beta blocker. You say that the enrollee has continued to have brachycardic episodes with weakness and 
feels unwell without syncope. You also say that you have recommended the use of a Holter monitor for 2 
weeks to assess further to determine the enrollee's risks. 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 Holter monitor. Our reviewer says that 
the requested use of a Holter monitor for 2 weeks not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no supportive evidence that the ordering practitioner documented 
any standard, non-Mobile Cardiac Outpatient Telemetry (MCOT), ambulatory electrocardiogram (ECG) 
monitoring. Therefore, the reviewer found there is insufficient documentation to support the medical necessity 
for an MCOT monitor 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 Holter monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Holter monitor for 2 weeks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you have been a patient with the clinic for 48 years 
and this clinic and doctors saved your life. The Plan denied your request. The Plan says the enrollee may use 
out-of-network providers to get some of their covered services. However, the enrollees out-of-pocket costs 
may be higher than if the enrollee uses our plan providers. 
 
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 visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart catheterization and ventriculography. 
 
You asked the Plan to pre-approve heart catheterization and ventriculography. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is 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 heart catheterization and 
ventriculography. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation provided does not support the 
rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization 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 heart catheterization and ventriculography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve heart catheterization and ventriculography.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee's needs can be provided in the hospital setting where they are now. 
 
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 the enrollee was admitted with acute respiratory failure in the setting of chronic 
obstructive pulmonary disease exacerbation and pulmonary fibrosis. The record indicates that the enrollee has 
ongoing acute care issues and still requires acute care services. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. 
 
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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown porcelain fused to high noble metal (D2750) 
Tooth #15. 
 
You asked the Plan to pre-approve the dental services. You say that you have pain when you eat and drink 
anything cold, so you would like the request approved. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
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. Crown porcelain fused to high 
noble metal (D2750) is a covered benefit but is limited to one procedure per tooth every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested crown porcelain fused to high noble metal (D2750) Tooth #15 was 
exhausted on date of service January 25, 2019. Therefore, we decided that the Plan does not have to pre-
approve crown porcelain fused to high noble metal (D2750) Tooth #15.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from January 9, 2019, through 
January 11, 2019. 
 
You asked the Plan to pay for inpatient services. You say that the claim was filed timely. The Plan denied your 
request. The Plan says they did not receive the claim until December 1, 2021. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for inpatient services was not filed until December 1, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for inpatient services provided from January 9, 2019, through 
January 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's 
medical condition requires further evaluation and treatment in the acute care hospital. 
 
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a stroke. The enrollee's 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, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480-26 billed for date of service April 18, 
2022. 
 You asked the Plan to pay for procedure code 70480-26. You say that you do not believe this is a bundled 
charge. The Plan denied your request. The Plan says payment for code 70480-26 is bundled into payment for 
code 70470-26. 
 
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 
70480-26 is a column II code to column I code 70470-26. 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 70480-26 billed for date of service 
April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge day management (99217) billed 
for date of service May 13, 2022. 
 
You asked the Plan to pay for observation care discharge day management. You say that the claim at issue was 
denied as a duplicate incorrectly. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
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 99217 is "Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.])" 
 
We find that CPT code 99217 is not supported in the case record. Specifically, a qualifying initial observation care service has not been billed for the enrollee. Based on this information, we decided that Medicare rules for 
coverage of observation care discharge day management have not been met. Therefore, we decided that the 
Plan does not have to pay for observation care discharge day management (99217) billed for date of service 
May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring (95885, 95909) services provided on 
February 28, 2022. 
 
You asked the Plan to pay for the neuromonitoring. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 codes 95885, & 95909 is Needle electromyography, each 
extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and 
latency/velocity study; limited and Nerve conduction studies; 5-6 studies. 
 
We find that CPT codes 95885, & 95909 are not supported in the medical record. Specifically, nerve 
conduction studies cannot be verified in the provided records. Nerve conduction studies measure amplitude and 
latency/velocity and should not be reported with pedicle screw stimulation. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring have not been met. Therefore, we decided that 
the Plan does not have to pay for neuromonitoring (95885, 95909) services provided on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a commode chair (E0165) provided on December 26, 2021. 
 
You asked the Plan to pay for the commode chair. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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 CPT code E0165 is not supported in the medical record. Specifically, this code was billed without 
a required modifier (RR). Based on this information, we decided that Medicare rules for coverage of the 
commode chair have not been met. Therefore, we decided that the Plan does not have to pay for a commode 
chair (E0165) provided on December 26, 2021.