Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no clinical progress shown. 
 
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 the services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. You have had prior 
therapy, and the documentation does not reveal that you require the unique skills of a professional therapist to 
provide treatment safely and effectively, 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 your condition or to prevent deterioration. You are to have a 
follow-up with a spine specialist to determine whether you need additional surgery. At this time, you can 
perform a home exercise program, until you are re-evaluated by the spine specialist, and a plan is determined. 
 
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 pre-approve additional physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided on December 6, 
2021. 
 
You asked the Plan to pay for the pain management services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the 
services billed. 
 
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 the pain management services 
provided on December 6, 2021, have been met. The records provided do not show the date of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to pay for the pain management services 
provided on December 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retroperitoneal ultrasound (76700) provided on October 
21, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says this claim is a duplicate of another claim which has 
already been paid. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules also say that an exact duplicate for institutional claims is a claim or claim line that exactly 
matches another claim or claim line with respect to certain elements. 
 
We find that this claim is not supported in the medical record. Specifically, the record shows that this is a 
duplicate of a claim that has been previously paid by the Plan. 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 retroperitoneal ultrasound (76700) provided on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (84443, 86431, 84439, 86038) provided 
December 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says a corrected claim is needed for this service to be paid. 
 
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 84443, 86431, 84439, & 86038 is not supported in the medical record. Specifically the 
codes billed were not valid for the service provided. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (84443, 86431, 84439, 86038) provided December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided November 10, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you bill the 
intermittent pneumatic compression therapy, compression sleeves and pump separately for reimbursement and 
are paid all the time form carriers separately. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided 
November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided on December 6, 
2021. 
 
You asked the Plan to pay for the pain management services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the 
services billed. 
 
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 the pain management services 
provided on December 6, 2021 have been met. In this case, the records provided do not confirm the date of 
service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the pain 
management services provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection procedure; radioactive tracer for identification of 
sentinel node (CPT code 38792-59-LT) provided on October 21, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says procedure code 38792-59-LT, an injection procedure; radioactive tracer for identification of 
sentinel node is documented in the operative note submitted for review; however, this procedure is considered 
inclusive to CPT code 38900-LT, a intraoperative identification (mapping) of sentinel lymph node(s) which 
includes injection of non-radioactive dye, when performed (Listed separately in addition to code for primary 
procedure); therefore the code cannot be verified. 
 
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 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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The operative report does not support dye injection preoperatively, 
and therefore, would be inclusive to mapping of sentinel node. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for injection procedure; radioactive tracer for identification of sentinel node (CPT code 38792-59-
LT) provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve facet joint injections. You say that you need these injections to avoid pain 
medications. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region, no more than four 
(4) diagnostic or therapeutic joint sessions will be considered medically reasonable and necessary per rolling 12 
months, in recognition that the pain generator cannot always be identified with the initial and confirmatory 
diagnostic procedure. 
 
We looked at the file and Medicare rules. The records show that you have already had four sessions in the 
previous 12 months. Based on this information, we decided that Medicare rules for coverage of facet joint 
injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint 
injections (64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve purchase of a portable oxygen concentrator. 
 
You asked the Plan to pre-approve purchase of a portable oxygen concentrator. 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 must follow Medicare rules. Medicare rules say that Only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of purchase of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve purchase of a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sealy mattress and box spring. 
 
You asked the Plan to pre-approve the requested non-medical mattress and box spring. You say that your 
condition would not be helped by a hospital bed. You feel that a new mattress is required and would be 
necessary for your health. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Sealy mattress and box spring.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on November 15, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
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 Genetic Testing provided on November 15, 2021 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tresiba FlexTouch. 
 
You asked the Plan to pre-approve Tresiba FlexTouch. You say that this requested item is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered 
under the enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tresiba FlexTouch.  
 
 Benefits for Tresiba FlexTouch may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stapedectomy provided on November 10, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the stapedectomy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the stapedectomy provided on November 10, 2021, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 29, 2020, to December 31, 2020. 
 
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 DRG was updated. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 064 (INTRACRANIAL HEMORRHAGE OR 
CEREBRAL INFARCTION WITH MCC). 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 services at issue in this case were not supported by the medical records. 
Our physician reviewer found the review indicates that the documentation supported a 2-day admission for 
further evaluation of a fall and weakness. Even though vasomotor nephropathy and hyponatremia are 
documented in the record, supporting medical record documentation was not found within the record. To 
support the diagnosis of hyponatremia, there should be evidence of a sodium level <135 mEq/L, a reason or 
suspected cause for the hyponatremia and specific treatment to address the hyponatremia. The documentation 
included a sodium level of 135, 140 and a diagnosis of asymptomatic mild hyponatremia. No reason or 
suspected cause was documented for the diagnosis of hyponatremia. DRG 066: INTRACRANIAL 
HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC is the more appropriate DRG.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 29, 2020, to December 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
August 21, 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 records submitted do not indicate that two separate services were performed/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 71045 is "Radiologic examination, chest; single view." 
 
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 the records show that a single 
anteroposterior (AP) chest x-ray was done on 8/21/21, and was compared to a prior study of 8/17/21. Since 
only one exam was done on the date of the disputed claim, the plan's position that this was a duplicate claim is 
validated. 
 
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 additional imaging services provided to the enrollee on August 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 4, 
2022. 
 
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 only 17 drug classes were counted per the lab results submitted.  
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 the review has determined that the medical records do not contain documentation of definitive laboratory 
results for 22 or moredrug classes, including metabolites to support the coding criteria for G0483 for the billed 
date of service 01/04/2022. Only 17 drug classes were counted per lab results submitted. 
 
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 January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 1, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
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 an epidural injection provided on 
November 1, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient readmission services provided to the enrollee from 
December 26, 2021 to January 15, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the second admission was within two days of discharge and was directly related to the 
first admission. 
 The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 were not medically reasonable or necessary. Our physician reviewer found the readmission 
itself was medically necessary. The patient presented for readmission on 12/26/21 with fever, altered mental 
status, elevated white blood cell count, hypoxemia, and radiographic evidence of pneumonia. However, 
regarding the question of whether the readmission resulted from a premature discharge from the same hospital, 
there was no primary documentation of the initial hospitalization. Notably, there was no discharge summary 
and discharge examination included in the submitted documentation. The only information submitted was a 
summary of the care provided which was included in the appeal letter. Without primary medical records, there 
is no evidence to support that the readmission did not result from a premature discharge. 
 
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 inpatient readmission services provided to the enrollee from December 26, 2021 to January 15, 
2022.