Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapy and speech therapy. 
 You asked the Plan to pre-approve home health services. You say that the 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 the clinical 
documentation does not provide any unmet physical therapy or speech therapy goals (patient modified 
independent with mobility tasks and has been given home exercise plan for mobility and cognitive tasks) 
thus the records do not show that home health physical or speech therapy services are required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain your level of function and/or prevent 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health physical therapy and speech therapy.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an accelerated Transcranial Magnetic Stimulation 
(TMS) program with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an accelerated TMS program with an OON provider. You say that the 
requested OON TMS program is 5 to 10 miles away and is accelerated. Whereas the Plan's network provider is 
a 50-mile drive, and their program consists of treatment 5 days per week for 6 weeks. You say that the 
accelerated and closer treatment option is more appropriate due to your anxiety. The Plan denied your request. 
The Plan says the accelerated TMS treatment is not indicated, and that the network provider's TMS program is 
adequate to meet the enrollee's medical needs. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 accelerated TMS program with an 
OON provider. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer 
found you do not require an accelerated Transcranial Magnetic Stimulation (TMS) therapy from an OON 
provider as the Plan can provide services utilizing contracted medical providers who are credentialed by the 
Plan. There is nothing unique about your condition that would make it medically necessary to see the requested 
OON provider. 
 
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 accelerated TMS program with an OON provider have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an accelerated Transcranial Magnetic 
Stimulation (TMS) program with an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BRCA1/2 panel testing (81433) provided on May 15, 2023. 
 
You asked the Plan to pay for BRCA1/2 panel testing. You say that this testing impacts clinical decision-
making. The Plan denied your request. The Plan says this test is duplicative of part of the multi-cancer panel 
(81432) that was already approved, and this test is considered non-covered by the Diagnostics Exchange 
program. 
 The Plan must follow Medicare rules. Medicare rules say that only tests approved for coverage for the date of 
service will be covered. The Invitae BRCA1/2 panel test is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of BRCA1/2 panel testing have not been met. Therefore, we decided that the Plan does not have to 
pay for BRCA1/2 panel testing (81433) provided on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
February 2, 2023. 
 
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 a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel rendered on February 2, 2023.
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 the enrollee's family does not want 
skilled nursing facility placement. You would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says the enrollee does not meet all the requirements for admission 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 that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. the documentation does not support that LTACH services are medically appropriate at 
this time. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A0431 and A0436 for date of service December 25, 
2022. 
 
You asked the Plan to pay for codes A0431 and A0436. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R57.0 has an Excludes1 note in relation to R55. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for codes A0431 and A0436 have not been met. Therefore, we decided that the Plan does not have to pay 
for codes A0431 and A0436 for date of service December 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the records provided support the need for 
proton beam therapy services. The Plan denied your request. The Plan says proton beam therapy is not 
considered medically reasonable and necessary in this case.  
 
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 proton beam therapy. Our reviewer says 
that the requested proton beam therapy is not considered medically reasonable and necessary in this case. Our 
physician reviewer found while proton therapy is not an experimental therapy, any potential benefit or 
detriment of proton therapy over standard intensity modulated radiation therapy (IMRT) is an investigational 
question. Other treatment approaches such as IMRT and image-guided radiation therapy (IGRT) are also highly effective and well tolerated.  Thus, whether proton therapy affords a benefit over other standard approaches 
(IMRT/IGRT) for prostate cancer is an area of investigation and remains controversial. To date, there are no 
compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. While the National Comprehensive Cancer Network (NCCN) 
guidelines consider proton therapy a reasonable alternative they do not describe it as being necessary in lieu 
of non-proton based treatment and are quite explicit in that there is no evidence of its superiority.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient clinic service (revenue code 0510) provided from 
June 12, 2023, to June 14, 2023. 
 
You asked the Plan to pay for outpatient clinic service. You say that this revenue code occurred within 24 
hours of the admission; therefore, the charge should be reimbursed. The Plan denied your request. The Plan 
says outpatient diagnostic services related to an inpatient stay within 72 hours of admission are deemed related 
to the admission and must be included on the bill for the inpatient stay. 
 
The Plan must follow Medicare rules. Medicare rules say that clinic diagnostic and non-diagnostic services 
performed during the 3 calendar days prior to the date of an inpatient admission by the same hospital are 
included in the inpatient payment.   
We looked at the file and Medicare rules. These services are included in the inpatient stay; therefore, the use of 
the outpatient clinic revenue code 0510 is not appropriate for this claim. Based on this information, we decided 
that Medicare rules for coverage of outpatient clinic service have not been met. Therefore, we decided that the 
Plan does not have to pay for outpatient clinic service (revenue code 0510) provided from June 12, 2023, to 
June 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on May 24, 2023. 
 
You asked the Plan to pay for outpatient services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says these services are bundled into the inpatient 
facility payment as the enrollee was admitted as inpatient from May 24, 2023, to May 27, 2023, at the same 
hospital (or an entity wholly owned or wholly operated by the hospital). 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that outpatient services which are related to a hospital admission and are provided by the hospital (or 
entity wholly owned or wholly operated by the hospital) occurring on the date of an inpatient admission must 
be billed with the inpatient admission. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient services have not been met. Specifically, these were performed by the hospital (or entity 
wholly owned or wholly operated by the hospital) where the enrollee was admitted as an inpatient on the same 
day. This means that this service should be billed as an inpatient service with an inpatient revenue code. 
Therefore, we decided that the Plan does not have to pay for outpatient services provided on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on May 10, 2023. 
 
You asked the Plan to pay for the 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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded". 
 
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 the services. Our reviewer says that the use of code 99223 is not supported by the records provided. Our reviewer found that the documentation supports an appropriate 
exam, but not an appropriate history or medical decision-making of a high level. 
 
We looked at this coder's review, the file, and Medicare rules. 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 the services (99223) provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90960 billed for March 1, 2023. 
 
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 procedure code 90960 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 90960 is end-stage renal disease (ESRD) related services 
monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other 
qualified health care professional per month. 
 
We find that CPT code 90960 is not supported in the medical record. Specifically, there are no records to 
support that the services were performed for the billed date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 90960 billed for March 1, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 16, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you have reported the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the absorptive dressing (A6252), conforming bandage 
(A6446), and tape (A4450) provided on June 02, 2022. 
 
You asked the Plan to pay for the absorptive dressing (A6252), conforming bandage (A6446), and tape 
(A4450). You say that the items should be covered. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the absorptive dressing 
(A6252), conforming bandage (A6446), and tape (A4450) provided on June 02, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (G2023, U0003, U0005, 99072) 
provided on May 5, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (G2023, U0003, U0005, 
99072) provided on May 5, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 24, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bottled water (A9270). 
 
You asked the Plan to pre-approve bottled water. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve bottled water (A9270).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services for date of service February 18, 2022, to 
March 19, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that cancellation of bill received. 
 
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 documentation shows that the Plan has denied this claim due to 
"cancellation of bill received". No additional information was provided on why these services are not payable 
as billed. No other denial rationale was provided. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for the home health services for date of service February 18, 2022, to March 
19, 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: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block (64493).  
You asked the Plan to pre-approve a lumbar/sacral facet joint block. 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 Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet certain criteria. 
 
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 lumbar/sacral facet joint block. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
documentation on physical exam that the facet joints are the cause of pain. Also, no more than 2 joints can be 
injected at the same time. 
 
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 lumbar/sacral facet joint block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lumbar/sacral facet joint block (64493).