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

 
We decided that the Plan does not have to pre-approve minimally invasive percutaneous sacroiliac (SI) joint 
fusion (27279), bone marrow aspirate (20939), and associated anesthesia (00630). 
 
You asked the Plan to pre-approve minimally invasive percutaneous SI joint fusion, bone marrow aspirate, and 
associated anesthesia. You say that the services are necessary. The Plan denied your request. The Plan says 
medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 minimally invasive percutaneous SI 
joint fusion, bone marrow aspirate, and associated anesthesia. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation is not evident regarding imaging studies that corroborate SI joint pathology that 
could benefit from the requested procedure. Moreover, multiple other plausible pain generators including at the 
lumbosacral spine are evident. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. Therefore, the requested minimally invasive 
percutaneous SI joint fusion, bone marrow aspirate, and associated anesthesia, in this case, is not medically 
reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of minimally invasive percutaneous SI joint fusion, bone marrow aspirate, and 
associated anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve 
minimally invasive percutaneous sacroiliac (SI) joint fusion (27279), bone marrow aspirate (20939), and 
associated anesthesia (00630).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aqua therapy pool. 
 
You asked the Plan to pre-approve aqua therapy pool. 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 whirlpool bath equipment is covered if patient is 
homebound and has a (standard)condition for which the whirlpool bath can be expected to provide substantial 
therapeutic benefit justifying its cost. 
 
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 aqua therapy pool. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that you are homebound. Provided records do not document that all other 
therapy options have been tried and failed to justify the cost of the requested equipment as required by the 
NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aqua therapy pool have not been met. Therefore, we decided that the Plan does 
not have to pre-approve aqua therapy pool.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you have been in a skilled nursing 
facility for eight weeks and aren't getting better. You say that you need to be in the LTACH because you need 
more intensive care than what you are getting now. The Plan denied your request. The Plan says the LTACH 
services you are requesting do not meet the requirements for approval. 
 
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 you appear to be stable and there are no services at the LTACH that are not already 
available and covered at the current facility. Transfer to the LTACH would not be clinically advantageous at 
this time and completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services received on January 26, 2022 and to 
waive the deductible for the removal of implant services received on April 15, 2022. 
 
You asked the Plan to pay for the dental services and to waive the deductible for the removal of implant 
services. You say that you disagree with the amounts owed. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to services that are received from an 
out-of-network provider.  
 
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.    
 
The removal of the implant services you asked the Plan to pay for falls within the out-of-network outpatient 
surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible which applies to services that are received from an out-of-network provider. This cost 
sharing is a contractual obligation that had not been met at the time the dental services and to waive the 
deductible for the removal of implant services was received on April 15, 2022. 
 
Therefore, we decided that the Plan does not have to pay for the dental services received on January 26, 2022 
and to waive the deductible for the removal of implant services received on April 15, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the abdomen and pelvis (74177). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that this CT is medically 
necessary as the enrollee has had a recent abnormal ultrasound. The Plan denied your request. The Plan says 
that the enrollee had a normal CT scan of the abdomen in August of 2022. Additional testing is not appropriate 
or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the abdomen and pelvis. 
Our reviewer says that the requested imaging is reasonable and necessary in this case. Our physician reviewer 
found the documentation indicates that the enrollee had an ultrasound on January 25, 2022, which showed an 
enlarged echogenic liver concerning for hepatic steatosis vs hepatocellular disease. The enrollee had a normal 
CT scan of the abdomen on August 24, 2022. Per Medscape Internal Medicine, a CT scan of the abdomen may 
be performed to assess the abdomen and its organs for tumors and other lesions, injuries, intra-abdominal 
bleeding, infections, unexplained abdominal pain, obstructions, or other conditions. Given the ultrasound 
findings from January, the requested computed tomography (CT) of the abdomen and pelvis (74177) is 
medically necessary and reasonable. 
 
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 CT scan of the abdomen and pelvis have been met. Therefore, we decided that 
the Plan has to pre-approve computed tomography (CT) of the abdomen and pelvis (74177).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records support the requested level of care. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies not used with external infusion pump, 
per cassette or bag (list drugs separately) (A4223) provided March 7, 2022, to March 10, 2022. 
 
You asked the Plan to pay for the infusion supplies. You say that the claims should be processing with a PR-96 
denial so that you are able to submit the claims to the secondary payer. Please reprocess the claims. The Plan 
denied your request. The Plan says this service is not covered by Medicare.  
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 A4223 is infusion supplies not used with external 
infusion pump, per cassette or bag (list drugs separately). 
 
We find that CPT code A4223-GY is not supported in the medical record. Specifically, the claim was billed 
with the GY modifier. The GY modifier indicates that an item or service is statutorily excluded, or the service 
does not meet the definition of Medicare benefit. The Plan also made several attempts to obtain additional 
information from the provider without success. Based on this information, we decided that Medicare rules for 
coverage of the infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately) 
(A4223) provided March 7, 2022, to March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 22, 2022. 
 
You asked the Plan to pay for the testing services. You say that medical records were provided. The Plan 
denied your request. The Plan says the testing is not covered for screening services. 
 
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. In this case, the records show that the test was ordered to determine if 
the enrollees current medication were having the best effects on her health. The risk analysis provided in the 
case file shows the testing was ordered by a specialist in lab diagnostic testing, who is not the enrollees 
treating physician. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on May 22, 
2022.
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 enrollee meets the medically 
necessary criteria for LTACH based on a primary complex respiratory condition and active treatment of 
multiple comorbidities that cannot be done at a lower level of care. The Plan denied your request. The Plan 
says the LTACH is not medically necessary, and the enrollee's needs are being met at the current acute 
hospital. 
 
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 the enrollee was admitted to the acute inpatient hospital with acute on chronic 
respiratory failure. He has interstitial lung disease and diabetes. The enrollee presented with shortness of breath 
and was intubated and placed in the intensive care unit. The record shows the enrollee is receiving appropriate 
care at the present acute care hospital. The enrollee does not require services at the LTACH that are not 
available at the acute care hospital where he is currently receiving 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits (97164). 
 
You asked the Plan to pre-approve 10 PT visits. You say that the enrollee cannot wait to have this PT and it is 
medically necessary. The Plan denied your request. The Plan says there is no clinical evidence to support the 
medical necessity of this examination or that the enrollee meets Medicare criteria for continued PT therapy 
services. 
 
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 10 PT visits. 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 that the enrollee has previously been treated with outpatient therapies 
and should be independent with a home exercise program. There is no documentation of a recent injury or 
decline in function. The additional therapy services are not an appropriate duration and frequency for treatment 
of the enrollees medical condition and therefore are not 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 10 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional physical therapy (PT) visits (97164).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 provided on December 22, 2021. 
 
You asked the Plan to pay for procedure code 99497. 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. 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 99497 
is a column II code to column I code 90792 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99497 provided on December 22, 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 the LTACH services. You say that the LTACH is medically necessary 
because they are extensive wounds requiring wound care. The Plan denied your request. The Plan says the 
LTACH is not medically necessary, and your needs can be met at another setting such as an acute rehabilitation 
facility, skilled nursing facility, nursing facility, outpatient setting or home care. 
 
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 at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting.  
 
 
 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 procedure code 99100 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that re-hospitalization will occur if you are discharged 
home. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.