Persius/hicric huggingface dataset:
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 the enrollee requires intensive inpatient rehabilitation 
with daily physician management, twenty-four hour specialized rehabilitation nursing and intensive therapies. 
The Plan denied your request. The Plan says admission to IRF was denied as not meeting criteria, is not 
medically necessary, and a lower level of care might be appropriate. Skilled nursing facility level of care was 
offered. The enrollee's care needs can be met at home with supervision and home health services, an assisted 
living facility with home health services or in a long-term care facility with part-time skilled services. 
 
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 enrollee has a past medical history of hypertension, arthritis and is living at home 
with weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the 
enrollee has a need for physical or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 1, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service February 13, 
2022. 
 
You asked the Plan to pay for procedure code 99283. You say that the enrollee was seen for two different chief 
complaints. The Plan denied your request. The Plan says payment for code 99283 is bundled into payment for 
code 99285. 
 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 99283 is a column II code to column I code 99285. 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 99283 
billed for date of service February 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by 
code E0652. 
 
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 a PCD is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not document 
at least four weeks of regular, daily, multiple-hour home usage of a non-segmented pump after a careful in-
person fitting, training, and supervision by a skilled technician. The criteria for coverage are not met and the 
E0652 PCD is 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 pneumatic compression device (PCD) described by code E0652.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that these services are medically necessary. The 
Plan denied your request. The Plan says these services can be provided in-network. 
 
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 physical therapy to be provided by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 current evidence-based medical 
guideline and peer-reviewed literature do not support the Superion spacer over the gold standard of lumbar 
laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
this device for this enrollees medical condition. The services are 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 Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on May 10, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that you want the Plan to pay for the service. The Plan 
denied your request. The Plan says the service at issue is not a covered benefit when performed during a 
medical eye examination.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is part of a routine eye examination. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when 
it is performed as part of a routine screening by a participating provider. This service was performed for 
medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for an eye refraction (92015) provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 50-trip limit. 
  
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
and from dialysis. The Plan denied your request. The Plan says you have exhausted your transportation 
benefits. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that 50 routine transports have been covered. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 50-trip limit.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the cervical spine 
without contrast. 
 
You asked the Plan to pre-approve an MRI scan. You say that the frequent falls the enrollee has had and 
concern for cervical myelopathy you are requesting an MRI of the cervical spine to evaluate for stenosis and/or 
cord compression, which would be able to be addressed surgically. The Plan denied your request. The Plan 
says that the enrollee has not completed 6 weeks of provider directed treatment, the provider directed treatment 
did not occur within the last 3 months, symptoms must be the same or worse after treatment to support 
imaging, and there was no contact with the enrollee's provider after completing treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI scan. Our reviewer says that 
the MRI of the cervical spine is medically necessary. Our physician reviewer found that the concern as 
indicated in letter of appeal is possible cervical stenosis/myelopathy. Given the clinical concern and history the 
MRI of the cervical spine is reasonable 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 an MRI scan have been met. Therefore, we decided that the Plan has to pre-
approve a magnetic resonance imaging (MRI) scan of the cervical spine without contrast.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service November 
30, 2021. 
 
You asked the Plan to pay for procedure code 87150. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87150 is bundled into payment for code 87500.  
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 87150 
is a column II code to column I code 87500. 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 87150 billed for date of service November 30, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85027 billed for date of service July 1, 2020. 
 
You asked the Plan to pay for procedure code 85027. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 85027 is bundled into payment for code 85025. 
 
 
 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 85027 
is a column II code to column I code 85025. 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 85027 billed for date of service July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted Molecular Pathology, SelectMDx test (81479) 
provided March 30, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are a CLIA-certified and CAP 
accredited clinical diagnostic laboratory and the sole source provider for the SelectMDx test. The Plan denied 
your request. The Plan says this test is considered not reasonable and necessary according to Medicare criteria. 
 
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 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the claim was billed with the 
GZ modifier. The GZ modifier identifies that 1) an item or service is expected to be denied as not reasonable 
and necessary, and 2) no advance notice of non-coverage was supplied to the member. Also, according to LCD 
L35160, MolDX will only cover tests that demonstrate analytical and clinical validity, and clinical utility at a 
level that meets the Medicare reasonable and necessary requirement. The Mo1DX site shows that the 
SelectMDx test has not met this technical assessment requirement.  The test is denied as it is considered not 
reasonable and necessary according to Medicare criteria. Based on this information, we decided that Medicare 
rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not 
have to pay for the unlisted Molecular Pathology, SelectMDx test (81479) provided March 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for cardiovascular device evaluations and a 
retroperitoneal ultrasound provided from January 27, 2022, to May 31, 2022. 
 
You asked the Plan to reduce the copayments for the device evaluations and ultrasound. You say that the 
copayments should only be $35. The Plan denied your request. The Plan says you were charged this cost 
sharing correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for diagnostic procedures and tests, including ultrasounds. 
 
 
 
 
 
 Date of Service Item Copayment per EOC Actual Charge 
January 27.2022 Device Evaluation $75 $62.97 
February 27, 2022 Device Evaluation $75 $75.00 
March 30, 2022 Device Evaluation $75 $62.71 
April 30, 2022 Device Evaluation $75 $62.21 
May 4, 2022 Ultrasound $75 $75.00 
May 31, 2022 Device Evaluation $75 $75.00 
Total:   $412.89 
 
You have been asked to pay a total of $412.89 for the device evaluations and ultrasound. The device 
evaluations and ultrasound fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to reduce the copayments for cardiovascular device 
evaluations and a retroperitoneal ultrasound provided from January 27, 2022, to May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 83550 provided on June 10, 2020. 
 
You asked the Plan to pay for code 83550. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says payment for the services billed is included in other services 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. In this case, we have confirmed that code 83550 
is a column II code to column I code 84466 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for code 83550 provided on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 13, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480 and 
80307. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also state that providers may bill services with a -59 modifier if the service billed with the modifier 
indicates a distinct procedural service. In this case, we have confirmed that code 83789 is a column II code to 
column I codes G0480 and 80307. While this service was billed with the -59 modifier, the medical records 
provided do not show that the service billed with the -59 modifier is a distinct procedural service. 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 
83789 billed for date of service April 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat Zilretta injection. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have knee 
osteoarthritis. You received a Zilretta injection in July of 2022 but there is no follow-up of your clinical 
condition after this injection. The submitted records do not support the use of a repeat Zilretta injection at this 
time. 
 
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 repeat Zilretta injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80050) provided June 13, 2020. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for lab services (80050) 
provided June 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (electric wheelchair). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you cannot walk and can only stand 
for transfers. You need a power wheelchair to go to medical appointments, to church, shopping and to get 
around the facility you live in. The Plan denied your request. The Plan says you are at a facility which provides 
skilled level of care. Durable medical equipment is covered by the Plan and Medicare for home use only. DME 
for use in a facility such as a SNF is prohibited under Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power operated vehicle is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a power operated vehicle (electric wheelchair).