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

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a Skilled Nursing Facility (SNF) in each benefit period. A benefit period begins on admission to a hospital or 
to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF 
care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from September 13, 
2021, to December 29, 2021. The Plan has covered 100 days of SNF care.  
 
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available and being provided at the health care setting being offered by the health plan.   
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 17, 2021, to 
October 5, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that you would like to pay for these services. The Plan 
denied your request. The Plan says this claim has been correctly denied. 
 
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 record clearly shows that you signed a self-pay financial consent form. The form states that you understand 
that insurance will not and cannot be billed for your treatment now of in the future and that your treatment and 
payment cannot be used for reimbursement by any insurance or carrier 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. 
Therefore, we decided that the Plan does not have to pay for physical therapy provided on September 17, 2021, 
to October 5, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the proton beam radiation therapy (PRBT) (Current Procedural 
Terminology (CPT) code 77523). 
 
You asked the Plan to pre-approve the PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says that a review of the current medical literature does not consider this service to be 
standard medical treatment for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found proton beam is allowed for stage IIIB definitive treatment with chemotherapy. 
 
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 PBRT have been met. Therefore, we decided that the Plan has to pre-
approve the proton beam radiation therapy (PRBT) (Current Procedural Terminology (CPT) code 77523).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
no in-network providers being available. The Plan denied your request. The Plan says prior prostate biopsy 
results were not provided. 
 
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 laboratory services provided on 
October 29, 2021, have been met. In this case, no medical records were provided detailing the enrollees 
history. Without these records, we are unable to assess the enrollees medical need for the laboratory services 
and how these services would assist in managing their medical condition. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on October 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services coded as 15777, 19342, 
19370 and 19371 provided October 21, 2021. 
 
You asked the Plan to pay for the surgical assistant services. You say that please find the attached requested 
records pertaining to the procedure on 10/21/2021. The attached records are all that are available since the 
enrollee was surgical only. The Plan denied your request. The Plan says procedures with a status indicator of 
1 are not eligible for assistant at surgery reimbursement. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services 
coded as 15777, 19342, 19370 and 19371 provided October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided to an end-stage renal disease (ESRD) 
patient on September 7, 2021. 
 
You asked the Plan to pay for the ESRD-related lab testing. You say that payment for these services should not 
be bundled. The Plan denied your request. The Plan says the ESRD facility is responsible for paying for this lab 
testing. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab testing provided to an end-stage renal disease (ESRD) patient on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolotherapy provided on January 18, 2022. 
 
You asked the Plan to pay for prolotherapy. The Plan denied your request. The Plan says Prolotherapy is 
considered alternative medicine and its effectiveness remains in dispute. 
 
The Plan must follow Medicare rules. Medicare rules say that medical effectiveness of Prolotherapy has not 
been verified by scientifically controlled studies. 
 
We looked at the file and Medicare rules. The rules say Prolotherapy has not been verified by scientifically 
controlled studies. Based on this information, we decided that Medicare rules for coverage of prolotherapy 
have not been met. Therefore, we decided that the Plan does not have to pay for prolotherapy provided on 
January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative approaches to 
treatment and is a good candidate for Vertiflex. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because Vertiflex is experimental/investigational. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, more research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on November 
10, 2021, and November 11, 2021. 
 
You asked the Plan to pay for subsequent hospital care. You say that these services are payable and were coded 
correctly. The Plan denied your request. The Plan says the principal diagnosis code submitted with this claim is not a valid principal diagnosis. ICD-10 code F05 (delirium due to known physiological condition) is to be 
coded after the underlying physiological condition. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the use of F05 (delirium due to known physiological condition) as a principal diagnosis is not 
supported. Specifically, coding guidelines indicate that the underlying physiological condition should be coded 
before F05. Based on this information, we decided that Medicare rules for coverage of subsequent hospital care 
have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99232) provided on November 10, 2021, and November 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services with an out-of-network provider. You say that you 
want the enrollee to see this provider. The Plan denied your request. The Plan says there is no medical need to 
receive these services out-of-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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) radiologic examination, 
spine, cervical (72050) radiologic exam, spine, thoracic (72070) radiologic examination, spine, lumbosacral 
(72100) provided December 29, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you are hoping that the Plan will 
reimburse you some of the cost for these x-rays. The Plan denied your request. The Plan says these services are 
not covered under the Plan benefits. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99203) radiologic examination, spine, cervical 
(72050) radiologic exam, spine, thoracic (72070) radiologic examination, spine, lumbosacral (72100) provided 
December 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve MRI. You say that you had an X-Ray that revealed a lump on your 
shoulder, so this MRI should be approved. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because no medical records were provided to support the need for this 
scan. 
 
The Plan must follow Medicare rules. Medicare rules say that to consider coverage for any item or service, the 
information submitted by the provider must corroborate the medical documentation and confirm that coverage 
criteria have been met.  
 
We looked at the file and Medicare rules. Your treating physician did not submit medical records to support 
this request. The Plan requested supporting records, but they were not submitted. Without medical records, it 
cannot be determined whether the requested MRI is medically reasonable and necessary for you. Based on this 
information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on January 19, 
2022. 
 
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 a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76700. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 20, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that nothing in either case alerted 
you that there were restrictions for the examination, nor could you find anything online that detailed all 
procedures. You also say that you would like this denial to be reversed. The Plan denied your request. The Plan 
says this service exceeds the frequency limitation in your benefit plan. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on September 20, 2021 and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 81455) provided on 
September 24, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Targeted genomic 
sequence analysis panel, code 81455, is non-covered by Medicare. Genetic testing procedures submitted with 
code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and 
will be denied automatically as not medically necessary. Therefore, we decided that the Plan does not have to 
pay for the laboratory service (CPT code 81455) provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99100 and 99140) provided on 
March 8, 2021. 
 
You asked the Plan to pay for the anesthesia services (99100 and 99140). You say that medical records are 
attached to reprocess the claim accordingly. The Plan denied your request. The Plan says procedure code 01200 
has been overturned. The Plan also says that procedure codes 99140 and 99100 remain denied as bundled 
services are not eligible for separate payment.  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 and 99140 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT code 99100 and 99140 are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services (99100 and 99140) have not been met. Therefore, we 
decided that the Plan does not have to pay for the anesthesia services (99100 and 99140) provided on March 8, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 22, 2021. 
 You asked the Plan to pay for the services provided. You say that the non-invasive option was used over a 
surgical procedure. The Plan denied your request. The Plan says this claim has not been billed with an 
appropriate modifier. 
 
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, we have confirmed that code 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on June 22, 2021.