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

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI), any joint of lower 
extremity; without contrast material (73721) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an MRI of the knee. You say that you have a lump, and you need this to be 
taken cared of as soon as possible. The Plan denied your request. The Plan says medically necessary care is 
available in network. 
 
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 magnetic resonance imaging (MRI), any joint of lower extremity; without contrast material (73721) to be 
provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health treatment to be provided by a 
provider that does not participate with Medicare. 
 
You asked the Plan to pay for the outpatient services. You say that on your own, you found a therapist through 
and online program at $60 a session. You would like reimbursement for the 6 sessions you have paid out of 
pocket and all future sessions. The Plan denied your request. The Plan says if you go to a provider who is not 
eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the outpatient mental health treatment to 
be provided by a provider that does not participate with Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 criteria for coverage are not met. Our physician reviewer found the enrollee has obstructive sleep apnea 
(OSA), obesity-hypoventilation syndrome (OHS) with chronic CO2 retention, and heart failure with preserved 
ejection fraction (HFpEF). There is no documentation of failure of outpatient bi-level positive airway pressure 
(BiPAP) therapy. The home ventilator is not covered for treatment of OSA or OHS. The enrollee does not have 
chronic obstructive pulmonary disease (COPD), neuromuscular disease, or thoracic restrictive disease. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60 additional routine transportation trips. 
 
You asked the Plan to pre-approve 60 additional trips. You say that you have no other way to get to doctor's 
appointments. The Plan denied your request. The Plan says you have exhausted this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 60 additional routine transportation trips.
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 you have degenerative disc disease and cannot stand 
for a long period of time. You are in constant pain and cannot walk without a walker. You say that your quality 
of life is in jeopardy. The Plan denied your request. The Plan says you do not require an IRF 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. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical 
history of fibromyalgia, spinal stenosis, degenerative joint disease, lap band surgery, depression and bipolar 
disorder and are living at home with difficulty ambulating. Your medical problems are stable and you have no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials (D4265) and primary closure of a 
sinus perforation (D7261). 
 
You asked the Plan to pre-approve biologic materials (D4265) and primary closure of a sinus perforation 
(D7261). You say that you need these procedures because you will have a hole once the tooth is removed. You 
say that your pain level is getting worse, and you need this procedure as soon as possible. The Plan denied your 
request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biologic materials (D4265) and primary closure of a sinus perforation (D7261).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded as 99291 provided on 
February 2, 2022. 
 
You asked the Plan to pay for the critical care services coded as 99291. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation does 
not support payment for code 99291 as billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation provided 
does not indicate the time spent performing critical care services. Based on this information, we decided that 
Medicare rules for coverage of the critical care services coded as 99291 have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care services coded as 99291 provided on February 2, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 14, 2022, billed with 
codes 81194, 81301, 81455, 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the requested testing should not be 
considered a diagnostic service but a prognostic indicator service that aids the treating provider with selecting 
the right cancer treatment options. The Plan denied your request. The Plan says the requested testing is not 
covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
 
 
 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 14, 2022, billed with codes 81194, 81301, 81455, 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin D assays testing (82306) provided December 29, 
2020. 
 
You asked the Plan to pay for the laboratory services. You say that you have attached additional documents for 
reconsideration for payment of claim as requested. The Plan denied your request. The Plan says this is not a 
Medicare benefit for the diagnoses listed and is done for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the vitamin D assays testing (82306) provided December 29, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for SNF admission. 
 
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 care. Our reviewer says that you 
do not meet criteria for SNF admission. Our physician reviewer found based on the documentation provided, 
you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You 
are not shown to have an acute decline in function. Daily skilled services are not shown to be required to 
establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and 
intermittent, can, as a practical matter, be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty. 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that this requested arthroplasty procedure 
is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says 
Medicare guidance says an imaging test that shows advanced joint disease is required before coverage for this 
procedure can be approved. 
 The Plan follows Medicare rules. Medicare rules say that the requested total knee arthroplasty is subject to the 
coverage criteria listed 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 a total knee arthroplasty. Our reviewer 
says that the requested procedure is not considered medically reasonable and necessary. Our physician reviewer 
found that the enrollee is a 74-year-old female being treated for unilateral primary osteoarthritis of the left 
knee. She was last seen on March 7, 2022, and had left knee pain with increased activity, pain while ascending 
and descending stairs, instability, and weakness. The March 15, 2022, computed tomography (CT) scan of the 
knee has impressions of degenerative changes in the left knee (severe in the medial tibiofemoral compartment 
and moderate-severe in the patellofemoral compartment). 
 
However, detailed documentation is not evident regarding objective findings corroborating the subjective 
complaints. Furthermore, the detailed documentation does not corroborate that the conservative treatment 
measures have been attempted for 3-months. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the enrollee does not satisfy the coverage criteria for the requested left total knee arthroplasty. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99152) provided on December 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 does not include 
documentation of the presence of an independent trained observer to assist in the monitoring of the patient's 
level of consciousness and physiological status. Therefore, this procedure 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 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dalvance. 
 
You asked the Plan to pre-approve Dalvance. 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Dalvance. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no documentation that the Dalvance at issue in this case 
meets Medicare criteria for safe and effective. Provided records do not document that all of the other antibiotics 
that the Streptococcus organism was sensitive to are inappropriate for this enrollee. The usual dosage of 
Dalvance for acute infection of skin and/or subcutaneous tissue is 1500 mg intravenous infusion as a single 
dose or 1000 mg infusion followed by a 500 mg second dose one week later. Dosing 500 mg weekly for four 
weeks is not supported by the Medicare-approved major drug compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dalvance have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Dalvance.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 4, 2021, billed with 
codes 81408, 81249, 81230, and 81291. 
 
You asked the Plan to pay for the genetic testing billed. 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 as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 4, 2021, billed with codes 81408, 81249, 81230, and 81291.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99212), chiropractic 
manipulative treatment (98940), low-level laser treatment (S8948), and the massage therapy (97124) provided 
on November 22, 2021. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says a referral was not 
provided by the enrollees primary care physician in this case. Additionally, the low-level laser treatment and 
massage therapy service are not covered under the contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. However, the Plan offers supplemental coverage of 
one chiropractic initial evaluation per calendar year.  
 
 
 We reviewed the case file and the Plans rules. Based on this information, we find that the services provided do 
not meet the Plans rules for coverage. Specifically, the record does not show that a referral was submitted by 
the enrollees primary care physician for the services provided in this case. The Plans contract states that the 
enrollee must first obtain a referral from their primary care physician before obtaining chiropractic services. 
Additionally, low-level laser treatment and massage therapy are not listed as covered benefits under the Plans 
contractual policy. Therefore, we decided that the Plan does not have to issue reimbursement for the office visit 
(99212), chiropractic manipulative treatment (98940), low-level laser treatment (S8948), and the massage 
therapy (97124) provided on November 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 1, 2022, to 
March 15, 2022. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was 
billed with an invalid type of bill. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the claim at issue was not billed with a valid type of bill code. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from March 1, 2022, to March 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on February 1, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the testing was not billed with a single code as required. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the gene panel testing provided on February 1, 2022.