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

 
We decided that the Plan does not have to pre-approve L4-5 spinal fusion with Minuteman device (22840, 
22612) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of lumbar spinal fusion with 
the Minuteman interspinous device in the setting of spinal stenosis have not been demonstrated in the peer-
reviewed literature. 
 
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 requested services are not considered medically reasonable and necessary in this case. The minuteman 
device is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L4-5 spinal fusion with Minuteman device (22840, 22612) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT, thorax, low dose for lung cancer screening, without 
contrast material(s) (CPT code 71271). 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 member quit smoking 24 years ago and the 
member is 84 years old.  
 
  
Therefore, we decided that the Plan does not have to pre-approve CT, thorax, low dose for lung cancer 
screening, without contrast material(s) (CPT code 71271).
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member would be more appropriate at a lower level of care. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cellulitis and osteomyelitis of the left foot. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on June 3, 2021. 
 
You asked the Plan to pay for the medical services. You say that these services were not related to the patient's 
hospice diagnosis. The Plan denied your request. The Plan says this claim should have been billed to Original 
Medicare. 
 
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 medical services provided on June 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for Procedure code 97110-GP-KX (x4) billed for date of service September 23, 2021.
You asked the Plan to pay for Procedure code 97110-GP-KX (x4). You say that you have provided medical records to support payment. The Plan denied your request. The Plan says this code is not supported in the medical record. The Plan contends that the more appropriate code for these services was G0151.
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 97110-GP-KX is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
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 97110-GP-KX (x4). Our reviewer says that code 97110-GP-KY is not supported in the medical record. Our reviewer found the medical records describe services performed in the home. There is a more appropriate code to report for service provided in the home. 
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 97110-GP-KX (x4) have not been met. Therefore, we decided that the Plan does not have to pay for Procedure code 97110-GP-KX (x4) billed for date of service September 23, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided October 11, 2021. 
 
You asked the Plan to pay for the emergency services. You say that that the provider is enrolled with Medicare 
and the Medicare provider enrollment letter is attached for review. Please review this claim and reprocess for 
payment promptly and accordingly. The Plan denied your request. The Plan says that that Medicare does not 
cover services that are not performed by a Medicare certified provider. 
 
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. The records show that the facility provided their temporary Medicare hospital 
enrollment letter which is dated before this date of service. The Plan has not provided any documentation to 
substantiate their reason to continue to deny. Therefore, we decided that the Plan has to pay for the emergency 
room services provided October 11, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services you received on January 8, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that the emergency medical staff 
was able to resolve your issue without you being transported. The Plan denied your request. The Plan says non-
transport ambulance services are not covered. 
 
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 January 8, 2022. 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 non-transport ambulance services you received on 
January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11043 billed for date of service July 16, 
2021. 
 
You asked the Plan to pay for procedure code 11043. You say that this code was billed correctly. The Plan 
denied your request. The Plan says procedure code 11043 is not supported in the medical record because the 
operative report does not indicate that the muscle and/or fascia was debrided. 
 
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 11043 is debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less. 
 
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 11043. Our reviewer says that procedure 
code 11043 is not supported in the medical record. Our reviewer found the procedure report does not include 
documentation of muscle debridement, and therefore cannot be verified.  The procedure report documents 
"Sutures removed and the dead tissue including epidermis, dermis and subcutaneous tissue was debrided out the debridement of the black dead tissue was excisional area of debridement was approximately 2 cm x 1 cm x 
1 cm down through the superficial tissues into the deeper tissues". The documentation does not confirm the 
depth of debridement performed.  
 
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 11043 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 11043 billed for date of service July 16, 2021.
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 LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and when the enrollee is ready to leave, she can safely receive care in another setting such as in a 
skilled nursing facility or at home with home health services. 
 
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 that the enrollee appears to be more stable  but should only require short-term 
additional acute care services, that the enrollee can safely receive at the current facility, until more appropriate 
for transfer to a lower 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 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 LTACH services. You say that LTACH admission is medically necessary and to sustain a safe discharge for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current hospital and does not require a transfer to an LTACH.
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 that the enrollee appears to be somewhat unstable still and requires short-term additional acute care services that the enrollee can safely receive at the current facility until more stable and appropriate for transfer. 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99152) provided on December 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older". 
 
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 use of code 99152 is not supported by the records provided. Our reviewer found that the procedure report documents "Anesthesia; 
Anesthesia type: IV meds and local". The documentation does not include enough detail to confirm the 
description of moderate sedation has been performed. The procedure does not support presence of an 
independent trained observer, and therefore cannot be verified. 
 
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 the services (99152) provided on December 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 10 physical therapy visits.
You asked the Plan to pre-approve an additional 10 physical therapy visits. You say that this care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says no further skilled therapy services are medically necessary at this time for the enrollee.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional 10 physical therapy visits.
Our reviewer says that additional skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy generally is not accepted as specific and effective therapy for the patient's condition beyond what was approved by the Plan. The documentation does not reveal that the enrollee continues to require the unique skills of a professional therapist to safely and effectively provide treatment. The documentation also does not reveal that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. The patient has persistent functional deficits and pain despite multiple prior therapy sessions. The documentation notes she has not had a formal diagnosis or workup and that her balance is worsening with falls. It would be prudent to follow up with her physician at this time prior to continuing any additional therapy to evaluate the etiology of her 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 an additional 10 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 10 physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia services (99100) provided on September 9, 2021.
You asked the Plan to pay for special anesthesia services. You say that you have provided records to support the service billed. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia services (99100) provided on September 9, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for assisted pool exercise therapy (97113) provided from August 6, 2020, 
to August 27, 2020. 
 
You asked the Plan to pay for physical therapy services. You say that these services were pre-approved, and 
you expected to only be responsible for a $15 copayment for each of these dates of service. The Plan denied 
your request. The Plan says that you have exceeded your combined in-and-out-of-network limit of $2,080 (in 
2020) for physical and speech therapy services, and you are responsible for these charges. 
 
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. First, the Plans 2020 contract states only that there is a combined limit of 
$2,040 (in 2019) for physical and speech therapy services. No such limit is mentioned in the 2020 contract for 
the 2020 Plan year. The 2021 contract does state that there is a similar limit for physical and speech therapy 
services in 2020; however, since this information was included in the 2021 contract, this information would not 
have been available to the enrollee at the time of services. Second, no previous claim information for physical 
therapy services provided in 2020 was submitted for review. There is no documentation to support that the 
enrollee has met or exceeded any Plan limit for physical therapy services in 2020. The Plans denial is not 
substantiated in this case. Therefore, we decided that the Plan has to pay for assisted pool exercise therapy 
(97113) provided from August 6, 2020, to August 27, 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy.
You asked the Plan to pre-approve sclerotherapy. 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 treatment of varicose veins 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 sclerotherapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does not indicate that the varicosities are symptomatic as defined by the coverage rules or that you have failed conservative therapy for a three month period. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy.