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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement that indicates that these tests are included in the dialysis rate. 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 end-stage renal disease (ESRD) provided on 
November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request 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 requested services. Our physician 
reviewer found that the enrollee has chronic right knee pain. He has tried conservative therapy with limited 
relief. This procedure is the subject of ongoing clinical trials and is considered experimental/investigational.  
Therefore, the request is deemed not medically reasonable and 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation (PVA), 
including cavity creation (22513). 
 
You asked the Plan to pre-approve the PVA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation (PVA) 
(percutaneous vertebroplasty (PVP) or kyphoplasty (PKP)) is covered in patients with the criteria listed in the 
Medicare Rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PVA. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found imaging shows fracture retropulsion into the 
canal which is a contraindication. 
 
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 PVA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the percutaneous vertebral augmentation (PVA), including cavity creation (22513).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a quantitative calcium scoring (75571). 
 
You asked the Plan to pre-approve a quantitative calcium scoring. You say that your care team saw something 
troubling on your electrocardiogram, and you prefer to stay as healthy as you can. You also say that you would 
like the Plan's decision to be reconsidered. The Plan denied your request. The Plan says Medicare does not 
cover screening calcium scoring for asymptomatic patients, for risk stratification, or for quantitative evaluation 
of coronary calcium. 
 
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 a quantitative calcium scoring. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient support in the peer-reviewed literature demonstrating a 
significant benefit of computed tomography (CT) imaging of the heart with quantitative evaluation of coronary 
calcium in guiding optimal management of this patient. Our reviewer also found that as such, CT imaging of 
the heart without contrast material with quantitative evaluation of coronary calcium is considered 
experimental/investigational for the evaluation and management of your medical condition. 
 
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 quantitative calcium scoring have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a quantitative calcium scoring (75571).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission due to a decrease in functional abilities. The Plan denied your request. The Plan says the IRF 
services requested are not considered medically reasonable or 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 medial 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for dates of service January 20, 
2022, to January 23, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem.  
 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 billed services. Our reviewer found that 
the enrollee admitted to the acute hospital with multifocal pneumonia and gastroenteritis. On the dates of 
service at issue, the records did not support that 2 of the 3 required components were supported. Specifically, 
there was no detailed interval history or medical decision making of high complexity. Therefore, the billed 
services cannot be supported.  
 
We looked at this physicians review, the file, and Medicare rules. 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 99233 billed for dates of service January 20, 2022, to January 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service October 30, 
2022. 
 You asked the Plan to pay for procedure code 99497. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99497 is bundled into payment for code 99223. 
 
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 99223. 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 99497 billed for date of service October 30, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve continued coverage for the portable gaseous oxygen system, rental 
(E0431) and oxygen concentrator, single delivery port (E1390). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that you are appealing the denial of 
coverage for the new oxygen equipment, set up and future months of payment. The Plan denied your request. 
The Plan says that the enrollee does not meet criteria as it has been more than 36 months since initial deliver 
and the enrollee has not had a break in service for more than 60 days. 
 
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 looked at the file and Medicare rules. The Medicare rules say that when the stationary and the portable 
oxygen equipment are replaced, a new 36-month rental period and new RUL is started for both the replacement 
stationary oxygen equipment and the replacement portable oxygen equipment. The records show that the 
enrollee initially received the equipment E0431 and E1390 on January 5, 2019. The oxygen equipment was 
picked up on January 31, 2023, and new equipment was delivered on February 13, 2023. Based on this 
information, we decided that Medicare rules for coverage of the oxygen equipment have been met. Therefore, 
we decided that the Plan has to pre-approve continued coverage for the portable gaseous oxygen system, rental 
(E0431) and oxygen concentrator, single delivery port (E1390).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable loop recorder. 
 
You asked the Plan to pre-approve implantable loop recorder. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are 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 implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee minimally symptomatic permanent atrial flutter (fatigue), 
remote coronary artery bypass grafting, heart failure with preserved ejection fraction, type 2 diabetes mellitus, 
hypertension, without a history of cerebrovascular accident or syncope, and a reliable seven-day noninvasive 
Holter monitoring. No specific information that would change the current medical management can be obtained from the proposed invasive procedure that cannot be obtained from an external monitor. Therefore, the enrollee 
does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantable loop recorder.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 27335-59-LT billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for code 27335-59-LT. You say that the physician performed arthrotomy with 
synovectomy knee anterior and posterior including popliteal area, which is clearly documented in the operative 
report. The Plan denied your request. The Plan says the use of the 59 modifier to allow for separate payment of 
code 27335-59-LT is not supported by the medical record. This code is considered inclusive to 27447-LT. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 27335-59-LT Our reviewer says that 
the use of the 59 modifier with code 27335-59-LT to allow for separate payment is not supported in the 
medical record. Our physician reviewer found the operative report does not support synovectomy was performed for more than "clean up", and therefore cannot be confirmed as a separate billing of synovectomy 
from total knee arthroplasty. The operative report documents "Synovectomy in the suprapatellar pouch as well 
as medial and lateral gutters was performed".  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 27335-59-LT have not been met. Therefore, we decided that the Plan does 
not have to pay for code 27335-59-LT billed for date of service August 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a Licensed Surgical 
Assistant (LSA) for date of service July 27, 2022. 
 
You asked the Plan to pay for the LSA services. You say that this surgical assistant was requested by the 
primary surgeon, so the services should be paid. The Plan denied your request. The Plan says a LSA is not an 
eligible provider type to bill Medicare. 
 
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 surgical assistant services provided 
by a Licensed Surgical Assistant (LSA) for date of service July 27, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 documentation does not specify any complex functional impairments or active 
medical issues thus the complexity of the enrollee's documented nursing, medical and rehabilitation needs 
would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
records do not document any acute or unstable medical conditions or injuries which would necessitate any 
further skilled therapy visits beyond what have already been approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardiac catheterization (93458). 
 
You asked the Plan to pre-approve the cardiac catheterization. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service 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 the cardiac catheterization. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records provided show normal stress perfusion. 
 
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 cardiac catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the cardiac catheterization (93458).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health services. 
 You asked the Plan to pre-approve home health services. You say that the requested home health services are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented, ongoing, home health or physical therapy needs. The enrollee is 
functioning at a level commiserate with a lower level of care (i.e., home exercise program, outpatient therapy, 
layperson supervision). As such, the requested, ongoing, home health and physical therapy services are not 
medically necessary or 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care you received from November 16, 2022, 
to November 23, 2022. 
 
You asked the Plan to pay for the services. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Medicare-covered chiropractic care.   
Review of the file shows that you were provided covered chiropractic services (98940) on November 16, 2022, 
and November 23, 2022. You have been asked to pay a $20 copayment for each service. These services fall 
within the chiropractic care benefit category. 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. 
 
The rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to 
correct a subluxation.  
 
The records show that the other chiropractic services (99203, 72100, 97810, 97811) at issue is not manual 
manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic care 
you received from November 16, 2022, to November 23, 2022.