Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on October 20, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says 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 patient's medical records. There was no documented contact with the attending/primary 
care physician. 
 
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 the 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 October 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from the 
individualized care at a LTACH and will reduce the return to hospitalization and is clinically stable for transfer. 
The Plan denied your request. The Plan says the enrollee's condition you do not meet all the requirements, care 
can be provided in the current inpatient hospital. 
 
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 
current acute care hospital.  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed with rails (E0296, E0305). 
 
You asked the Plan to pre-approve a total electric hospital bed with rails. You say that the enrollee has chronic 
health failure and severe weakness. The Plan denied your request. The Plan says Medicare does not cover this 
item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed with rails (E0296, E0305).
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. The Plan denied your request. The Plan says the 
enrollee is receiving the appropriate inpatient care and currently unstable for transfer. 
 
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 
current acute care hospital. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the care needed to ensure a safe discharge. The Plan denied your request. The Plan says 
the enrollee's medical needs are being met in the current setting. 
 
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. All medically necessary care is being provided 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 long term acute care hospital (LTACH) services.
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 services are necessary to ensure your ability to 
transition back to independent living. The Plan denied your request. The Plan says the services you need can be 
provided safely in another setting such as 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 you do not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic testing provided on July 26, 2022. 
 
You asked the Plan to pay for the diagnostic testing. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that this service does not meet the coverage requirements in the 
applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD). 
 
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 has not provided a Medicare rule to substantiate their 
denial. Therefore, we decided that the Plan has to pay for diagnostic testing provided on July 26, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on July 26, 2022, billed with 
codes 15860, 38999, and 22999. 
 
You asked the Plan to pay for the services as billed. You say that this should be paid including all billed codes. 
The Plan denied your request. The Plan says payment was made for most of the billed services; however, the 
codes 15860, 38999, and 22999 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 15860 is intravenous injection of agent (eg, fluorescein) 
to test vascular flow in flap or graft. The definition of code 38999 is Unlisted procedure, hemic or lymphatic 
system. The definition of code 22999 is Unlisted procedure, abdomen, musculoskeletal system.  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services as billed. Our reviewer says that the services as 
billed are not supported by the records. Our reviewer found for code 15860 the operative report does not 
include documentation to support intravenous injection to test vascular flow in flap or graft. In this case, there 
is not enough information to confirm this procedure has been performed. For codes 38999 and 22999, the 
record does not include documentation to support an unlisted procedure.  Documentation should be thorough 
when claiming an unlisted procedure or service. In this case, confirmation cannot be made for an unlisted code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services provided on July 26, 2022, billed with codes 15860, 38999, and 
22999.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Propel sinus implant procedure. 
 
You asked the Plan to pre-approve the requested sinus procedure. You say that this procedure would be 
beneficial. The Plan denied your request. The Plan says current clinical studies do not support this treatment. 
 
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 requested sinus procedure. Our 
reviewer says that the requested sinus procedure is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has chronic sinusitis with concha 
bullosa. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the 
requested service. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.   
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 requested sinus procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Propel sinus implant procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an LDCT scan for lung cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the requested LDCT is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee does not have a smoking history of at 
least 20 pack years. Therefore, we decided that the Plan does not have to pre-approve an LDCT scan for lung 
cancer screening.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U provided on December 8, 2022. 
 
You asked the Plan to pay for procedure code 0241U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 0241U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0241U 
provided on December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PWC replacement. 
 
You asked the Plan to pre-approve a PWC replacement. You say that your current power wheelchair is broken. 
The Plan denied your request. The Plan says that it has not been five years since you received your current 
power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that the RUL of DME is determined through program 
instructions. In the absence of program instructions, carriers may determine the RUL, but in no case can it be 
less than five years. 
 
We looked at the file and Medicare rules. The records show your current power wheelchair was authorized on 
April 23, 2020, which is less than five years ago. Therefore, we decided that the Plan does not have to pre-
approve a PWC replacement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (0241U) provided on December 7, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (0241U) 
provided on December 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on April 4, 2022, to 
April 29, 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 payment is included in the SNF payment. 
 
The Plan must follow Medicare rules. The rules say that physical therapy, speech-language pathology services, 
and occupational therapy are bundled into the SNFs global per diem payment for a residents covered Part A 
stay. 
 
We looked at the file and Medicare rules. The file shows that the physical therapy services were performed in a 
SNF. Payment for these services is included in the SNF payment. Therefore, we decided that the Plan does not 
have to pay for the physical therapy services rendered on April 4, 2022, to April 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 52317 billed for date of service December 2, 
2022. 
 You asked the Plan to pay for procedure code 52317. You say that the procedures are separately payable and 
should not be denied for bundling. The Plan denied your request. The Plan says payment for code 52317 is 
bundled into payment for code 52356. 
 
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 52317 
is a column II code to column I code 52356. 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 52317 billed for date of service December 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound, abdominal aorta, (76706) provided on 
December 14, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that the service performed was appropriate with the 
diagnosis code. The Plan denied your request. The Plan says the billed diagnosis code is inconsistent with the 
billed procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for abdominal aortic aneurysm (AAA) for beneficiaries when certain criteria have been met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the 
ultrasound, abdominal aorta, (76706) provided on December 14, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on August 31, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the laboratory services based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for the laboratory services provided on August 31, 2020.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2078) provided on October 31, 
2022. 
 
You asked the Plan to pay for the opioid treatment services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says coverage rules are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. 
 
We looked at the file and Medicare rules. An individual provider billed the service, rather than an approved 
facility. Based on this information, we decided that Medicare rules for coverage of the opioid treatment 
services have not been met. Therefore, we decided that the Plan does not have to pay for opioid treatment 
services (G2078) provided on October 31, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 
for October 27, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that the initial evaluation is always included in the 
allowance for a minor surgical procedure. 
 
We looked at the file and Medicare rules. Procedure code 99285 was related to and billed on the same day as 
minor surgical procedure code 12001. Payment for code 99285 is included in the global surgical payment for 
12001. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services billed 
with code 99285 for October 27, 2022.