Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95926-59 billed for date of service 
September 13, 2021. 
 
You asked the Plan to pay for procedure code 95926-59. You say that this code should be paid. The Plan 
denied your request. The Plan says this code is not supported in the medical record. 
 
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 95926 is short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower 
limbs, in addition to other neuromonitoring services performed.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 95926-59. Our reviewer says that code 
95926-59 is not supported by the medical record. Our reviewer found this procedure was not found in any of the medical documentation submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95926-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95926-59 billed for date of service September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit (99214) and the laboratory 
services (80076, 85027) provided on January 18, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
 Your contract with the Plan clearly says that you must pay $10 for each covered visit or consultation in an 
outpatient location with your primary care physician (PCP) or other primary care provider. Additionally, you 
must pay $10 per day for other Medicare-covered laboratory tests that are not fecal immunochemical (FIT) 
tests. 
 
You have been asked to pay $20 ($10 copayment x 2) for the office visit with your primary care physician and 
the laboratory services provided. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for the office visit (99214) 
and the laboratory services (80076, 85027) provided on January 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
19, 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 this was not reported correctly. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on September 19, 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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 appears to be unstable and requires additional acute care services that can 
be safely provided at the current facility until the enrollee is stable for transfer to a lower level of care. There 
are no services available at the LTACH which the enrollee requires that are not available at the acute care 
facility where the enrollee 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 computed tomography (CT) scan of the abdomen and pelvis to be provided by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor. 
 
You asked the Plan to pre-approve cardiac rhythm monitor. You say that the enrollee needs this to help with 
heart rate. The Plan denied your request. The Plan says the requested procedure is not medically necessary. 
 
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 cardiac rhythm monitor. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation to 
suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent indication for an 
implantable loop recorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac rhythm monitor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the knee. 
 
You asked the Plan to pre-approve an MRI of the knee. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the knee. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the xray description of a possible 
chondroid lesion represents a red flag.  While not typical, the described puntate calcifications may be seen with 
chondroid tumors which include chondrosarcoma and other more common benign lesions of bone. 
Nonetheless, further evaluation with an MRI will be necessary to clarify. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the knee have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the knee.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pay for the admission. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be received in another setting. 
 
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 pay for the admission. Our reviewer says that the 
requested admission is not medically reasonable or necessary. Our physician reviewer found that there are no 
identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in 
a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pay for admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is 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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that you have 
very severe chronic obstructive pulmonary disease (COPD). There was a very slight increase in PaC02 in 
February 2021; it is not known whether the patient was acutely ill at that time. You may qualify for and benefit 
from bilateral positive airway pressure (BiPAP) during sleep, with or without the average volume-assured 
pressure support (AVAPS) mode. But Medicare does not pay for a ventilator when used as bilateral positive airway pressure (BiPAP). 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 29105 billed for date of service April 8, 
2021. 
 
You asked the Plan to pay for procedure code 29105. You say that these services were coded correctly. The 
Plan denied your request. The Plan says payment for code 29105 is bundled into payment for code 24650 billed 
on the same claim. 
 
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 29105 
is a column II code to column I code 24650. 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 procedure code 29105 billed for date of service April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (code D0150) you received on 
January 25, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you had no idea that you had had a 
comprehensive oral exam before.  You said that you had to switch to a new dentist and since you were only a 
few months away from being eligible, you believe this should be covered. The Plan denied your request. The 
Plan says you were not eligible for a comprehensive oral exam on January 25, 2022. 
 
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. Your Evidence of Coverage 
clearly states that you are covered for comprehensive oral exam once every 36 months.  Records show that you 
received a covered comprehensive oral exam on April 10, 2019.  You were not eligible for another 
comprehensive oral exam until after April 10, 2022. 
 
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 pay for the 
comprehensive oral exam (code D0150) you received on January 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic procedure to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a therapeutic procedure to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 therapeutic procedure to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pilot 24 Lite battery/backup power for a continuous 
positive airway pressure (CPAP) machine. 
 
You asked the Plan to pre-approve a Pilot 24 Lite battery/backup power for a CPAP machine. You say that the 
item is necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that for any item to be covered by Medicare, it must 
1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other 
applicable Medicare statutory and regulatory requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Pilot 24 Lite battery/backup power for a CPAP machine have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Pilot 24 Lite battery/backup power for a continuous 
positive airway pressure (CPAP) machine.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after May 
25, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that you have not reached your prior level of function 
yet. The Plan denied your request. The Plan says the denial of authorization for continued SNF care is correct. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care after May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria was not 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 the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the note submitted with by the provider with the initial request for a sacroiliac injection 
dated 4/8/2022, stated that the enrollee reported the last bilateral SI joint injection that she received on 
8/17/2021 reduced her pain by at least 50% for 6 weeks and she was able to move in ways that were too painful before. This is contradictory to the office visit note dated 9/27/2022 where the provider documented the 
enrollees issues had been about the same since the last visit and the member did not feel the SI injections 
helped.  The medical record has indicated that the previous sacroiliac joint injections did not effectively relieve 
the enrollees pain. The review has determined that the enrollee does not meet the coverage criteria for this 
request. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 23, 
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 this was not reported correctly. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with a single code. The plan has already paid for a single code in this case. 
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 laboratory services provided to the enrollee on 
November 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient prostate surgery to be provided by an out-of-network (OON) facility.

You asked the Plan to pre-approve inpatient surgery. You say that you want to be able to have this surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this facility is out-of-network with the Plan and your surgery can be performed at an in-network facility.

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 inpatient prostate surgery to be provided by an out-of-network (OON) facility.