Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the remaining 9 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says 2 visits have been approved; the remaining 9 visits are 
denied as 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 the enrollee's 
condition. Our physician reviewer found the enrollee has received 174 visits. The recertification does not 
include rationale for continued therapy in view of response to previous therapy. 
 
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 the remaining 9 additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82607 and 83036 billed for date of service 
July 21, 2022. 
 
You asked the Plan to pay for procedure codes 82607 and 83036. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these tests have no 
relation to any diagnosis reported on this claim and therefore are non-covered as screening tests. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, procedure codes 82607 and 83036, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for procedure codes 82607 and 83036 billed for date of service July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for February 9, 
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 codes 83520 and 87798 are 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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. 
 
We find that CPT codes 83520 and 87798 are not supported in the medical record. Specifically, these are not 
otherwise specified codes and a description of not otherwise specified codes is not included. 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 codes 83520 and 87798 billed for February 9, 2023
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve the sclerotherapy. You say that the enrollee has recurrent pain, heaviness 
and severe swelling, and difficulty with walking and fatigue. You also say that the enrollee meets the criteria 
for the ablation therapy. The Plan denied your request. The Plan says the records indicate that saphenous reflux 
is present in the left truncal (trunk) veins. The Plan says that the right truncal vein is not greater than 4 
millimeters. The Plan also says that sclerotherapy is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated. 
 
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 sclerotherapy. Our reviewer says 
that the requested sclerotherapy is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee has undergone saphenous vein reflux treatment. Therefore, the reviewer found that the requested sclerotherapy is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the sclerotherapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sclerotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the enrollee's condition requires 
paravertebral joint injections. The Plan denied your request. The Plan says based on the documentation 
provided, the enrollee does not meet Medicare guidelines that show a medical reason facet joint injections are 
needed. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is inadequate physical examination of the enrollee's lumbar spine. 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on May 24, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee is bed 
confined, confused, has decubitus ulcers, and status post of shortness of breath. You also say that due to the 
enrollee's condition at the time of transport, any other means of transport would be unsafe.  The Plan denied 
your request. The Plan says the ambulance transportation from the hospital to the enrollee's assisted living 
facility was not medically necessary.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service and ground mileage. 
Our reviewer says that the ambulance services were not medically necessary.  Our physician reviewer found the enrollee was transported from an acute care facility to a rehabilitation facility 
via stretcher. The record does not indicate that the enrollee's condition was such that other methods of 
transport, such as stretcher, are contraindicated or that the expertise, services and lifesaving equipment that 
only a fully equipped ambulance can provide was required. The elements of coverage criteria are not satisfied. 
 
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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on May 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator placement. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a spinal cord stimulator is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found performing surgery at the same time as 
placement of a spinal cord stimulator is not the standard of care. There are no studies that support this 
approach. The services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator placement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on April 3, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when medically reasonable 
and 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 pay for the definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
medical record sent by the provider shows a definitive UDT panel for multiple drug classes was performed but 
does not show screening test results which are positive or inconsistent with prescription medications, dosing 
schedules, or history and expected results. The review has determined that the definitive urine drug testing 
(UDT) for 22 or more drug classes (G0483) provided on April 3, 2023, did not meet the coverage criteria. 
 
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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on April 3, 2023.
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 enrollee's medical management and rehabilitation 
needs require inpatient rehabilitation stay and close physician supervision. The Plan denied your request. The 
Plan says the records show the enrollee doing well with therapy and able to perform bed mobility, transfers, 
and self-care activities without need for physical assistance, and requiring contact guard assistance for 
ambulation.  The Plan says that the enrollee can reasonably be expected to continue recovery with therapies at a 
lower level of care with similar success.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the laboratory services and the 
pembrolizumab injections provided on April 13, 2023, to May 25, 2023. 
 
You asked the Plan to waive the cost share for the lab services and the injections. You say that you believed 
theses services would be fully covered. 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 $50 
copayment for in-network lab services provided at an outpatient hospital. Your contract with the Plan also 
clearly says that you must pay 20% coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay $47.78, which is less than the standard copayment for the lab services provided on 
May 22, 2023. This item/service falls within the outpatient diagnostic tests and therapeutic services and 
supplies 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.  
 
You have also been asked to pay $1,765.92, which is less than 20% coinsurance of the allowed amount for the 
injection provided on April 13, 2023. You have also been asked to pay $1,978.78, which is less than 20% 
coinsurance of the allowed amount for the injection provided on May 25, 2023. These items/services fall within 
the Medicare Part B prescription drugs 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. Therefore, we decided that the Plan does not have to waive the cost share 
for the laboratory services and the pembrolizumab injections provided on April 13, 2023, to May 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the sleep study provided on April 24, 
2023. 
 
You asked the Plan to waive the coinsurance for the sleep study. You say that you never received the results 
from the test and you should not have to pay the cost share. 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for the sleep study. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 total you owe is $117.48 ($587.39 allowed amount x 20% = 
$117.48). Therefore, we decided that the Plan does not have to waive the coinsurance for the sleep study 
provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431), biologic materials to aid in soft and osseous tissue regeneration, per site (D4265), bone 
replacement graft for ridge preservation - per site (D7953), infiltration of sustained release therapeutic drug, per 
quadrant (D9613), and guided tissue regeneration, natural teeth  resorbable barrier, per site (D4266). 
 
You asked the Plan to pre-approve the dental services. You say that these services should be covered as they 
are medically necessary and you cannot afford to pay the denied billing codes yourself. You also say that you 
are in a lot of pain and really need your services approved. The Plan denied your request. The Plan says any 
dental services that are not listed as a covered code will not be covered.  
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 an 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions, not to include cytology or biopsy procedures (D0431), biologic materials to aid in soft and 
osseous tissue regeneration, per site (D4265), bone replacement graft for ridge preservation - per site (D7953), 
infiltration of sustained release therapeutic drug, per quadrant (D9613), and guided tissue regeneration, natural 
teeth  resorbable barrier, per site (D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on January 17, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the psychotherapy. You say that the provider is in-network with the Plan. The 
Plan denied your request. The Plan says the provider is out-of-network, and the services were not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 psychotherapy provided on January 17, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 96374 billed for date of service March 15, 
2023. 
 
You asked the Plan to pay for procedure code 96374. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 96374 is bundled into payment for code 22511. 
 
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 96374 
is a column II code to column I code 22511. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 96374 billed for date of service March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism, electric (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you are requesting reconsideration you 
suffer from arthritis and gait disorder. You are unable to get up from a chair on your own. The Plan denied your 
request. The Plan says the request is not medically necessary because the records show you do not have 
arthritis of the hip or knee, or a neuromuscular disorder. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
 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 seat lift mechanism. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found you do not require a power seat 
lift chair per guideline criteria. The clinical documentation and physical therapy documentation is limited in 
terms of your level of function with transfers and mobility. You are noted to have impaired ability to ambulate 
and perform transfers but there is limited information in terms of the level of independence in terms of 
performing transfers. There is no clear indication of a neuromuscular disease or severe arthritis. Therefore, the 
requested power seat lift chair is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism, electric (E0627).