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

 
We decided that the Plan does not have to pay for an additional unit of procedure code 01992 rendered on June 
22, 2022. 
 
You asked the Plan to pay for the additional services. You say that this should be paid for. The Plan denied 
your request. The Plan says there is no documentation that two separate services were performed. 
 
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 01992 is "Anesthesia for diagnostic or therapeutic nerve 
blocks and injections (when block or injection is performed by a different physician or other qualified health 
care professional); prone position." 
 
We find that the additional unit is not supported in the medical record. Specifically, there is no documentation 
that multiple anesthesia services were rendered on this date of service. Based on this information, we decided 
that Medicare rules for coverage of the additional services have not been met. Therefore, we decided that the 
Plan does not have to pay for an additional unit of procedure code 01992 rendered on June 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission stating the enrollee will need continued medical oversight for their current 
medical issues. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
LTACH services requested do not meet the requirements for approval. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketamine assisted psychotherapy provided out-of-
network. 
 
You asked the Plan to pre-approve the Ketamine assisted psychotherapy. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Ketamine assisted psychotherapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Ketamine does have an off-label citation for use in certain cases of severe, 
treatment resistant depression, however efficacy, safety, and tolerability of ketamine in adults with non-
treatment-resistant depression as well as other mental disorders has not been adequately studied. 
 
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 Ketamine assisted psychotherapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Ketamine assisted psychotherapy provided out-of-network.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on November 9, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that you were sent a letter dated October 18, 2022, 
from the Plan stating that the services with this provider would not be covered effective November 15, 2022, 
which is after the date of service of November 9, 2022, in your appeal. The Plan denied your request. The Plan 
says that services provided by a mental health counselor are not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
We looked at the file and the Medicare rules. The file does not show that the Plan provided notice that the 
psychotherapy would not be covered for date of service November 9, 2022. In fact, the Plan provided notice to 
you in a letter dated October 18, 2022, that the services with this provider would not be covered effective 
November 15, 2022. Under Medicare rules, this means the psychotherapy is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for psychotherapy provided on November 9, 2022. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675 and E0673). 
 You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered for 
preventative services or in ambulatory surgical centers. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. Medicare will pay for 
durable medical equipment that is needed for use in the home. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression devices (E0675 and E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine physical exam provided on November 10, 2021. 
 
You asked the Plan to pay for the routine physical exam. You say that this visit should be covered at 100% as 
the coding for this visit was not used in 2021. The Plan denied your request. The Plan says the member used 
the routine physical exam benefit on April 30, 2021, with a different provider. 
 
The Plan contract says the Plan covers an annual physical exam. Limited to one exam per calendar year. 
 
We looked at the file and the Plans rules. The file shows that you used the routine physical exam benefit on 
April 30, 2021, with a different provider. Therefore, we decided that the Plan does not have to pay for a routine 
physical exam provided on November 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission stating it is physically and medically necessary. The Plan denied your request. 
The Plan says the enrollee does not meet the guidelines for admission to an IRF. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 enrollee clearly exceeds criteria for 
coverage. The Plan denied your request. The Plan says LTACH services are not medically necessary. 
 
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 all medically necessary care is being provided in the current acute care setting. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee needs this due to worsening heart 
failure. The Plan denied your request. The Plan says there remains a dearth of randomized, blinded clinical 
studies examining the long-term clinical outcomes to establish the value of CardioMEMS in patient 
management. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining the long-term clinical 
outcomes to establish the value of CardioMEMS.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 11721. You say that the physician provided medically necessary 
services and the claim should be processed for payment. The Plan denied your request. The Plan says payment 
for code 11721 is bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service August 31, 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. The Plan denied your request. The Plan says the enrollee's records 
do not show the need for an intensive team, services needed can be provided safely in other settings, a skilled 
nursing facility, home with home health services or home with outpatient therapy. 
 
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. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 45385 and 45381 billed for date of service 
August 16, 2022. 
 You asked the Plan to pay for procedure codes 45385 and 45381. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 45385 and 45381 is 1. The MAI value for these codes is 2. You billed 2 
units of each pf these codes, exceeding the MUE. It appears as though you may have submitted these codes for 
payment multiple times instead of filing a corrected claim, which may be the reason for this issue. Based on 
this information, we decided that Medicare rules for coverage of procedure codes 45385 and 45381 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 45385 and 45381 billed 
for date of service August 16, 2022.  
 
Please note that if it was your intent to submit a corrected claim instead of a second claim, you will need to 
reach out to the Plan directly.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for continuous glucose monitor (CGM) supplies provided on January 4, 
2023. 
 
You asked the Plan to pay for the CGM supplies. You say that this claim was bundled in error. The Plan denied 
your request. The Plan says that that the code billed (A4239) has a status indicator of 'P' on the Medicare 
Physician Fee Schedule Relative Value File, which means payment for this code is always bundled 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that the code billed has a status 
indicator of P on the Medicare Physician Fee Schedule Relative Value File.  This is not a valid reason for 
denial in this case.  The Medicare Physician Fee Schedule Relative Value File status indicator only applies to 
items and services paid under the Medicare Physician Fee Schedule.  The CGM supplies in dispute were 
provided by a durable medical equipment (DME) vendor, NOT a physician.  As a result, the DME fee schedule 
applies here. The Plan has provided no argument or proof that the CGM supplies in dispute are not payable 
under the DME fee schedule. Therefore, we decided that the Plan has to pay for continuous glucose monitor 
(CGM) supplies provided on January 4, 2023.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hospital emergency room services provided on 
August 18, 2022. 
 
You asked the Plan to reimburse you for hospital emergency room services. You say that you were in Toronto 
visiting a dying family member and you stepped off the sidewalk into a waiting car and you slipped and 
slammed your right shoulder into the pillar of the door opening and your cousin took you to the hospital. The 
Plan denied your request. The Plan says the services at issue could not be verified as urgent or emergent 
care.  
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of hospital emergency room services 
have been met. Specifically, there is a lack of medical records showing that your condition was the result of an 
emergency as there are no true emergency room notes. Therefore, we decided that the Plan does not have to 
reimburse you for hospital emergency room services provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurosurgery care with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve neurosurgery care. You say that this physician is the most qualified to treat 
your condition. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 
you can be treated by an in-network neurosurgeon. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 neurosurgery care. Our reviewer says 
that you do not meet criteria for the requested out-of-network care. Our physician reviewer found the Plan has 
at least 3 in-network neurosurgeons who can consult you on your case. These providers could further evaluate 
your condition and make appropriate recommendations. There is not anything unique about your condition that 
would make it medically necessary for you to receive out-of-network care. The Plan has in-network providers 
who meet the standards of care to treat you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neurosurgery care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve neurosurgery care with an out-of-network (OON) provider.