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

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 15, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says ordering a multi-drug panel of definitive (confirmation) urine drug tests that are not used in 
management of the enrollee 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a multi-drug panel of definitive (confirmation) urine drug tests was performed. However, the provided 
records did not show abnormal urine drug screening results that warranted follow-up confirmation testing or 
signs of drug abuse to justify definitive testing. Many drugs tested were not applicable to the clinical history 
and treatment of this patient. Only antidepressants and antipsychotic medications were prescribed. Therefore, 
multi-drug panel of definitive (confirmation) urine drug tests that are not used in management of the enrollee is 
not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on October 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90837) and comprehensive community 
support services (H2015) provided from March 11, 2022, through April 8, 2022. 
 
You asked the Plan to pay for psychotherapy (90837) and comprehensive community support services 
(H2015). You say that you don't understand how one provider can get paid but not another from the same 
facility. The Plan denied your request. The Plan says a mental health counselor is not eligible to perform 
psychotherapy and CPT code H2015 is not a not valid for Medicare purposes.  The Plan must follow Medicare rules. Medicare rules say that there are certain individuals and entities that 
frequently attempt to enroll in Medicare but are not eligible to do so. Medicare rules say that providers must 
report services correctly with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy (90837) and comprehensive community support services (H2015) have not been 
met. Specifically, a mental health counselor is not eligible to receive Medicare payment. In addition, CPT code 
H2015 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT code H2015 is not valid 
for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of 
psychotherapy (90837) and comprehensive community support services (H2015) have not been met. Therefore, 
we decided that the Plan does not have to pay for psychotherapy (90837) and comprehensive community 
support services (H2015) provided from March 11, 2022, through April 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiogram provided on October 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for echocardiogram. You say that the claim has not been paid in full or under the 
terms of the contract for the services provided to this patient. The Plan denied your request. The Plan says the 
services were provided out-of-network and were not approved in advance. 
 
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 echocardiogram provided on October 11, 2021, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid, 3 to 5 targets, 
(87631) provided on December 20, 2021. 
 
You asked the Plan to pay for the respiratory pathogen panel. You say that the service should be covered. The 
Plan denied your request. The Plan says there is a more appropriate code to describe the services provided. 
 
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 87631 is i Infectious agent detection by nucleic acid 
(DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, 
parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 
 We find that CPT code 87631 is not supported in the medical record. Specifically, the file indicate there were 
more than 5 targets. Based on this information, we decided that Medicare rules for coverage of the respiratory 
pathogen panel have not been met. Therefore, we decided that the Plan does not have to pay for the infectious 
agent detection by nucleic acid, 3 to 5 targets, (87631) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from November 1, 2021, through 
December 29, 2021. 
 
You asked the Plan to pay for acupuncture. You say that CPT code 97810 and 97811 were denied but 
acupuncture is a covered benefit for low back pain according to Medicare guidelines. You say that these 
services were medically necessary, and the services should be approved for payment. The Plan denied your 
request. The Plan says a licensed acupuncturist is a non-covered provider type. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, an acupuncturist is a non-covered provider type. 
Therefore, we decided that the Plan does not have to pay for acupuncture provided from November 1, 2021, 
through December 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 19, 
2020, to September 10, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from August 19, 2020, to September 
10, 2020.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Remicade (Infliximab). 
 
You asked the Plan to pre-approve Remicade. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says that step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Remicade. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has a 
diagnosis of Crohn's disease of large intestine with rectal bleeding. In this case, the Plan requires a trial of 
Humira (Adalimumab) before they will approve the requested drug. The patient has not tried Humira at this 
time. However, their provider writes that, given the enrollee's high systemic inflammatory load and prior 
failures of vedolizumab and ustekinumab, the enrollee would benefit greatly from Remicade (Infliximab) over 
Humira (Adalimumab). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have been met. Therefore, we decided that the Plan has to pre-
approve Remicade (Infliximab).  
 
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 anesthesia services provided to the enrollee on November 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted was only for electrophysiologic (EP) study, with the 
radiofrequency ablation record. 
 
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 the denied codes is: 
 
CPT 00537: 
 
Anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation 
 
 
 CPT 01922: 
 
Anesthesia for non-invasive imaging or radiation therapy 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT codes 01916-01936 describe 
anesthesia for radiological procedures, specifically, CPT 01922:  Anesthesia for non-invasive imaging or 
radiation therapy. The anesthesiology provider billed CPT code 01922 along with CPT code 00537. However, 
there does not appear to be any documentation in the anesthesia records for CPT code 01922. The criteria for 
coverage for CPT code 01922 have not been met. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services provided to the enrollee on November 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix. 
 
You asked the Plan to pre-approve Epifix. You say that you can barely walk and it is taking a toll on your 
physical and mental health. The Plan denied your request. The Plan says the enrollee cannot have more than 10 
applications of Epifix. 
 
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 Epifix. Our reviewer says that Epifix is 
not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had 
been using Aquacel, ABD pad with Hypafix tape and is using the walking boot. It was also noted that the 
enrollee had already received and used 10 Epifix grafts. She had been treated with antibiotics for the foot 
wound being infected with MRSA. It was reported that her wound infection was improving but the wound size 
was not decreased. Epifix was requested. However, based on the Epifix having not been shown to significantly 
help improve the wound, there is insufficient support made for continuing another 10 days of this graft. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epifix.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is unable to return home currently 
due to her mobility. The Plan denied your request. The Plan says that skilled services can be provided on an 
intermittent outpatient basis, in a long-term care facility, or at the home with home health care services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
SNF services are not medically reasonable and necessary. The enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is already 
ambulating 100 feet. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, as a practical matter, can be provided at a 
lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) scanning computerized 
ophthalmic diagnostic imaging, posterior segment, with interpretation and report (92133) visual field 
examination (92083) provided on January 24, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that please see attached authorization request and 
medical records that may be needed to process this request. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 the outpatient office visit (99213) scanning 
computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report (92133) visual 
field examination (92083) provided on January 24, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a viscosupplementation injection. 
 
You asked the Plan to pre-approve a viscosupplementation injection. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that the dose and frequency of administration of 
viscosupplementation injections should be consistent with the FDA approved labeling. 
 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 viscosupplementation injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has failed viscosupplementation injections in the past. The elements of the coverage criteria 
are not satisfied. The requested service is not recommended. 
 
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 viscosupplementation injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a viscosupplementation injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage below fascia (28003) provided on 
December 3, 2021. 
 
You asked the Plan to pay for the incision and drainage below fascia (28003). The Plan denied your request. 
The Plan says an assistant surgeon may not be paid for procedures with a status indicator of 1. 
 
  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 28003. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
incision and drainage below fascia (28003) have not been met. Therefore, we decided that the Plan does not 
have to pay for the incision and drainage below fascia (28003) provided on December 3, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax, without contrast 
(71250). 
 
You asked the Plan to pre-approve a CT scan of the thorax without contrast. You say that the requested CT 
scan is medically necessary. The Plan denied your request. The Plan says that the requested CT scan does not 
meet criteria. 
 
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 scan of the thorax without 
contrast. Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee 
is a past smoker with a suspicious lung nodule. Biopsy is planned via navigational bronchoscopy. This 
procedure involves a specific CT protocol that allows the CT imaging to be used to locate the nodule during 
bronchoscopy. The CT scan done in May cannot be used for the procedure. 
 
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 scan of the thorax without contrast have been met. Therefore, we decided 
that the Plan has to pre-approve a computed tomography (CT) scan of the thorax, without contrast (71250).  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax and 
abdomen. 
 
You asked the Plan to pre-approve a CT scan of the thorax and abdomen. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 
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 
a computed tomography (CT) scan of the thorax and abdomen.