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

 
We decided that the Plan does not have to pay for infectious agent detection services (87631) provided on 
December 7, 2021. 
 
You asked the Plan to pay for infectious agent detection services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says there is a more appropriate 
code that should be billed for the services rendered. 
 
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 infectious agent detection services 
(87631) provided on December 7, 2021, have been met. Specifically, no documentation was obtained from the 
enrollees ordering provider detailing their medical history and why the testing was ordered. Without this 
information, we are unable to determine the medical necessity of the ordered testing. Therefore, we decided 
that the Plan does not have to pay for infectious agent detection services (87631) provided on December 7, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for myocardial perfusion imaging services (78452) provided on 
February 2, 2022. 
 
You asked the Plan to pay for myocardial perfusion imaging services. You say that you would like this claim 
reprocessed based on multiple exams having taken place. The Plan denied your request. The Plan says this 
claim has correctly denied due to the absence of required medical documentation. 
 
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 78452 is myocardial perfusion imaging, tomographic 
(SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first 
pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress 
(exercise or pharmacologic) and/or redistribution and/or rest reinjection 
 
We looked at the file and Medicare rules. In this case, the documentation supports one unit of 78452 which was previously approved and paid. A second unit of code 78452 is not supported for payment. Based on this 
information, we decided that Medicare rules for coverage of myocardial perfusion imaging services have not 
been met. Therefore, we decided that the Plan does not have to pay for myocardial perfusion imaging services 
(78452) provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. You say that your provider submitted a continuity of care 
services request and you missed your appointment. The Plan denied your request. The Plan says you must 
receive care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 provider at issue in this case is not a network provider with the Plan. 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 office visit. Our reviewer says that based on the medical records 
provided there is no documentation that there is anything unique about your condition that would make it 
medically necessary to continue care with the provider. 
 
 Our physician reviewer found based on the medical records provided there is no documentation that your 
medical management and/or follow-up care cannot be safely transitioned to an in-network specialist 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 an office visit have not been met.  
 
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 an office visit. Therefore, we decided that the Plan 
does not have to pre-approve an office visit to be provided by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on July 11, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not under hospice at the 
time the transport took place. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on July 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 6, 2021. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. The Plan confirmed with the provider that the provider did not order this test. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 6, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on January 10, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for wound care. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the OON service provided is excluded in the member's 
plan. 
 
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 wound care provided 
on January 10, 2022 by an out-of-network (OON) provider.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical 
therapy and occupational therapy services, but the medical records provided do not clarify why you require an 
intensive inpatient rehabilitation therapy program, and why continued therapy in the present skilled nursing 
facility is not appropriate. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from April 13, 2020, to April 
14, 2020. 
 
You asked the Plan to pay for the inpatient hospital 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 provided no supporting evidence to deny payment for 
these services based on Medicare coverage criteria. The Plan provided no medical records for review. 
Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from April 13, 2020, 
to April 14, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
December 23, 2021. 
 
You asked the Plan to pay for the determination of refractive state. You say that you feel the refraction should 
fall under routine coverage and not medical. The Plan denied your request. The Plan says refractions are not 
payable when performed in conjunction with a medical examination or if it is performed alone. 
 
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 the determination of refractive state is performed in conjunction 
with a routine examination. 
 
We looked at the file and the Plan's rules. The record shows that you received the refractions in conjunction 
with a medical examination and evaluation for the diagnosis of Vitreous Degeneration, Bilateral, which is not 
covered. Based on this information, we decided that the Plan's rules for coverage of the determination of 
refractive state have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the anti-reflective coating (V2750), progressive lens 
(V2781), and polycarbonate or equal lens (V2784) provided on June 2, 2021. 
 
You asked the Plan to pay more for the anti-reflective coating, progressive lens, and polycarbonate or equal 
lens. You say that you were not aware that you had to pay out of pocket. The Plan denied your request. The 
Plan says this claim processed correctly, as the $250 allowance was applied to this claim for the eyewear 
purchase. 
 
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 up to a $250 allowance for supplemental eyewear every year. 
 
We looked at the file and the Plan's rules. The record shows that the complete $250 allowance was applied to 
the services rendered on June 2, 2021, and your supplemental eyewear allowance had been exhausted. Based 
on this information, we decided that the Plan's rules for coverage of the anti-reflective coating, progressive 
lens, and polycarbonate or equal lens have not been met. Therefore, we decided that the Plan does not have to 
pay more for the anti-reflective coating (V2750), progressive lens (V2781), and polycarbonate or equal lens 
(V2784) provided on June 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you have no 
daily skilled nursing or therapy needs. 
 
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 physician reviewer 
found that you are at a supervision level for transfers and ambulation, and independent for eating, hygiene, 
dressing, and toileting. You do not have documented skilled nursing or skilled therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of your 
condition. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve a SCS trial. 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 no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless 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 a SCS trial. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found having failed a prior trial of a SCS, there is no indication for another trial. The request is not medically reasonable or 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 a SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 6, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you called 
the ambulance because you required glucose due to your blood sugar level. You also say that you were not 
transported, and feel the Plan should pay the ambulance bill as no transportation was required. The Plan denied 
your request. The Plan says your plan covers ambulance transportation only when you are actually transported 
by ambulance. The Plan also says that since you were not transported by this ambulance, the service is not 
covered by your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 6, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.  
 
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on August 6, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92960 billed for date of service August 7, 
2021. 
 
You asked the Plan to pay for procedure code 92960. You say that this code is supported in the medical record. 
The Plan denied your request. The Plan says procedure code 92960 is not the appropriate code for the service 
rendered. This code is not covered for emergency cardiac defibrillation and this CPT code describes a planned 
elective procedure. Also, if a planned elective external cardioversion is performed by a provider reporting 
critical care time, the time to perform the elective external cardioversion should not be included in the critical 
care time. 
 
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 92960 is elective (nonemergency) external electrical 
cardioversion. 
 
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 procedure code 92960. Our reviewer says that while the code itself was supported in the medical record, it was not billed appropriately in order for it to be paid. Our 
reviewer found the following services included in critical care when performed during the critical period: 
Procedure codes - 93598,71045,94760,43752,92953,94002 and 36000. Any services performed that are not 
included in this listing should be reported separately. Facilities may report the above services separately. The 
information on the claim form attached was only billed with procedure code 92960, and no -59 modifier was 
appended that would allow for separate payment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 92960 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 92960 billed for date of service August 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the trifocal eyeglass lens and anti-reflective lens 
coating provided on February 17, 2022.  
You asked the Plan to pay more for the trifocal eyeglass lens and anti-reflective lens coating. You say that your 
plan gives you a $150.00 credit every 24 months. You also say that credit was assured at the time of service. 
The Plan denied your request. The Plan says your $150 eyewear benefit allowance was exhausted with this 
purchase. 
 
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 up to a $150 allowance every 24 months for eyewear. 
 
We looked at the file and the Plan's rules. The record shows that the complete $150 allowance was applied 
toward the eyewear provided on this February 17, 2022 date of service, and your eyewear allowance has been 
exhausted. Based on this information, we decided that the Plan's rules for coverage of the trifocal eyeglass lens 
and anti-reflective lens coating have not been met. Therefore, we decided that the Plan does not have to pay 
more for the trifocal eyeglass lens and anti-reflective lens coating provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in a lot of pain. The Plan 
denied your request. The Plan says the trial did not have a 50% improvement with pain. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulation is only covered under certain 
medical indications. 
 
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 services. Our physician 
reviewer found that the enrollee has post-laminectomy syndrome. He takes Percocet, Gabapentin, Baclofen and 
Duloxetine for pain. He has psychological clearance for a SCS. However, after the completion of the SCS trial, 
the physician documented that it "significantly helped with respect to his pain". There was no change of in 
number per day Percocets used documented. There is no numerical documentation of pain relief. The 
requirement is clear documentation of 50% improvement in pain or a 50% decrease in analgesics. Neither is 
documented. Until this is clearly documented, the request is deemed not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.