Persius/hicric huggingface dataset:
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 has been unable to stay out 
of the hospital for more than 5 days without readmission. The services are necessary to provide the enrollee 
with the care needed and to prevent readmission. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided 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 99140 billed for date of service January 16, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that medical records were submitted for review. 
The Plan denied your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service January 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on October 
10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services at issue have 
been billed correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to ESRD provided on October 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you have a chronic cough and 
would like to rule out any cancer. The Plan denied your request. The Plan says you do not meet criteria for 
LDCT lung cancer screening. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that you quit smoking more than 15 years ago. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0382 rendered on August 22, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code is statutorily excluded from coverage. 
 
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 A0382 is "Bls routine disposable supplies." 
 
We find that CPT code A0382 is not supported in the medical record. Specifically, this code has a status 
indicator of X, which means that it is excluded from coverage. 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 procedure code A0382 rendered on August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code A4557 rendered on September 14, 2022. 
 
You asked the Plan to pay for the services. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that this procedure has been billed and allowed the maximum number of times 
allowed by the payment policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not specified what payment policy is being used to deny this code. 
The plan must specify with Medicare statute is being used to deny services. Therefore, we decided that the Plan 
has to pay for procedure code A4557 rendered on September 14, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart Implantable Pulse Generator 
(LPG-One unit). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has an unclear effect on long-term clinical outcomes, and a relatively high 
risk of complication. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device and the procedure are currently considered investigational. This is not recommended by 
any scientific and professional societies/associations as a part of Advanced Heart Failure management guidelines. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Optimizer Smart Implantable Pulse Generator (LPG-One unit).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72110) provided on 
November 17, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 x-ray exam of the lumbar spine (72110) provided on November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system for use on an approved 
power wheelchair. 
 
You asked the Plan to pre-approve the power seat elevation system. You say that you need this feature due to 
your limited range of motion in your arms. Without it, you cannot perform any daily tasks without assistance. 
The Plan denied your request. The Plan says this feature cannot be covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
Although this feature may be appropriate for you, neither Medicare nor your health plan provide coverage for 
this item. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system for 
use on an approved power wheelchair.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for services provided on June 3, 2022. 
 
You asked the Plan to pay for the services provided on June 3, 2022. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the appeal 
was not submitted within 60 days of the denial. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has failed to forward any of the requested documentation 
to support their decision. The case file includes a Notice of Dismissal indicating that the appeal was not 
submitted timely. There is no record of what services were billed or when or why they were denied. It is the 
burden of the Health Plan to substantiate their decision with evidence. In this case, the Health Plan's decision 
has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for 
services provided on June 3, 2022.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for services provided on May 27, 2022. 
 
You asked the Plan to pay for the services provided on May 27, 2022.. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the appeal 
was not submitted timely. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has failed to forward any evidence to support their 
decision. The case file includes a Notice of Dismissal indicating that the appeal submitted beyond the 60-day 
filing timeframe. The file does not include evidence of the claim to support what services were billed or the 
Plan's initial denial to support when and why the services were denied. It is the burden of the Health Plan to 
substantiate their decision with evidence. In this case, the Plan's decision has not been substantiated so we must 
find in your favor. Therefore, we decided that the Plan has to pay for services provided on May 27, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on November 10, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that the foot surgery was medically necessary. 
The Plan denied your request. The Plan says that the self-administered drugs are not covered by Medicare. 

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on November 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for 
treatment of your health problem. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion surgery  
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 8, 2022, billed 
with codes 81345, 81272 and 81314. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
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 
September 8, 2022, billed with codes 81345, 81272 and 81314.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266) and fixed partial 
denture sectioning (D9120). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and without these services 
an abscess can form. The Plan denied your request. The Plan says these services are not covered by the Plan's 
dental 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 the 
guided tissue regeneration (D4266) and fixed partial denture sectioning (D9120).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 0245U is bundled into payment for code 0018U. 
 
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 0245U 
is a column II code to column I code 0018U. 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 0245U billed for date of service May 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), a chest x-ray (CPT 71045), 
a swallowing function x-ray (CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240) provided on 
October 4, 2022. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040), a chest x-ray (CPT 71045), a swallowing 
function x-ray (CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240). You say that the services 
were medically necessary. The Plan denied your request. The Plan says the services were performed at a 
nursing home (via mobile van/portable x-ray), which are denied as an excluded place of service. 
 
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 a neck/spine x-ray (CPT 72040), a chest x-ray (CPT 71045), a swallowing function x-ray  
(CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240) have not been met. Therefore, we decided 
that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), a chest x-ray (CPT 71045), a 
swallowing function x-ray (CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240) provided on 
October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service November 1, 
2022. 
 
You asked the Plan to pay for the billed services. You say that a corrected claim was sent. The Plan denied 
your request. The Plan says the service is redundant. 
 
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 CPT code G0481 is not supported in the medical record. The Plan paid for drug testing code 
G0480. There is no indication that additional testing was provided. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code G0481 billed for date of service November 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve the 10 additional therapy services. You say that you are appealing the Plan's 
denial. The Plan denied your request. The Plan says the requested additional physical therapy visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition beyond what was approved by the Plan. You have had prior 
therapy, and the documentation does not reveal that you require the unique skills of a professional therapist to 
provide treatment safely and effectively, that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy services.