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

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON PT services. You say that you want to be able to go to the OON 
provider.  The Plan denied your request. The Plan says there is appropriate care in-network, and as such, the 
OON 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The provider at issue in this case is not a network provider with the Plan. 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 OON PT services. Our reviewer says that the requested OON PT care is 
not shown to be medically reasonable and necessary.  Our physician reviewer found the Plan indicated that 
they have approved 12 in-network physical therapy sessions already for the enrollee. The documentation does 
not reveal extenuating factors that would require this enrollee to change the physical therapy to out of network 
for the same services. The documentation does not reveal that the services are an emergency.  
 
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 OON PT services have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the OON PT services. Therefore, we decided that the 
Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole. 
 
You asked the Plan to pre-approve Pantoprazole. You say that the enrollee continues to suffer from significant 
acid reflux. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 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 pre-approve Pantoprazole.  
 
Benefits for Pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 20, 2022, to July 21, 
2022, billed with evaluation and management codes 99222-25 and 99232. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the level of care 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 codes 99222-25 and 99232 is initial hospital care, per day, for 
the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; 
A comprehensive examination; and medical decision making of moderate 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 problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit, and subsequent hospital care, per day, for the evaluation and management of a patient, 
which requires at least 2 of these 3 key components: An expanded problem focused interval history; An 
expanded problem focused examination; medical decision making of moderate 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 
responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at 
the bedside and on the patient's hospital floor or unit. 
 
We asked our physician 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 practitioner services provided. Our reviewer says that 
the level of care is not supported. Our reviewer found that the notes do not support this level of service for 
either initial note or follow up notes. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on July 20, 2022, to July 21, 2022, billed with 
evaluation and management codes 99222-25 and 99232.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 18, 2023, billed 
with procedure code 75774-59. 
 
You asked the Plan to pay for the services as billed. You say that this was billed correctly.  The Plan denied 
your request. The Plan says the 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 75774 is angiography, selective, each additional vessel 
studied after basic examination, radiological supervision and interpretation (List separately in addition to code 
for primary procedure). 
 
 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 as billed. Our reviewer says that the code is not 
supported.  Our reviewer found the procedure report does not include documentation of angiography, selective, 
each additional vessel studied after basic examination. CPT 75774 is reported for each additional vessel studied 
after the basic, initial study. It involves manipulating the initial study. It involves manipulating the catheter into 
additional second, third, or higher order vessels within a vascular family, and performing injection of contrast 
and taking additional films. This description was not found in procedure report, and therefore, the code cannot 
be verified. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on January 18, 2023, billed with procedure code 75774-
59.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services.  
 You asked the Plan to pre-approve home health services. You say that it is felt that the requested 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 enrollee 
has a medical history of multiple comorbid conditions and was recently discharged from a skilled nursing 
facility. Clinical documentation shows that enrollee has had acute clinical status change; however, the records 
show that home health skilled nursing services were refused by enrollee thus are not required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition 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 home health skilled nursing services.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines. 
The Plan says at the present time, the enrollee's condition 
requires ongoing medical care in the current setting.  
 
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 pay for procedure code 13132 billed for date of service March 23, 
2022. 
 You asked the Plan to pay for procedure code 13132. The Plan denied your request. The Plan says payment for 
code 13132 is bundled into payment for code 17110. 
 
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 13132 
is a column II code to column I code 17110. 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 13132 billed for date of service March 23, 2022.
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 is currently 
hemodynamically and electrically stable. You say the LTACH can provide the necessary care and to avoid 
unnecessary problems derived from immobility. The Plan denied your request. The Plan says the LTACH 
services are not medically necessary, and the enrollee's needs are being met at the current hospital setting.  
 
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 was admitted to the acute care hospital with acute coronary syndrome, 
acute kidney injury, and complicated by cardiac arrest and respiratory failure, urinary tract infection, deep vein thrombosis, and urinary retention requiring intubation, antibiotics, and anti-coagulation. The enrollee appears 
to be improving with current treatment and should only require short-term additional acute care services that 
can safely be provided at the current facility until more stable and appropriate for transfer to a lower level of 
care. The enrollee does not require services at the LTACH that are not already available at the current facility.  
 
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 parenteral nutrition supplies provided on March 28, 2023. 
 
You asked the Plan to pay for parenteral nutrition supplies. You say that the claim is billed correct. The Plan 
denied your request. The Plan says these codes 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 B4199 is parenteral nutrition solution; compounded 
amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any 
strength, over 100 grams of protein  premix. The CPT Code Manual definition of code B4224 is parenteral 
nutrition administration kit, per day. The CPT Code Manual definition of code B4220 is parenteral nutrition 
supply kit; premix, per day. 
 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 parenteral nutrition supplies. Our reviewer says that these 
codes do not meet criteria for payment. Our reviewer found the records do not include sufficient documentation 
to verify the date of service billed. Medical records only include services through March 27, 2023. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parenteral nutrition supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for parenteral nutrition supplies provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the DecisionDx-SCC genetic testing provided on March 24, 2023.  
 
You asked the Plan to pay for the DecisionDx-SCC genetic testing. You say that this is a Medicare-covered 
test.  The Plan denied your request. The Plan says that there was no interpretation and report of the testing. As 
such, the billed code cannot be verified.  
 
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 indicates that there was not an interpretation and report of the results of 
this testing; however, we found that the results were included in the appeal request including information about 
the test rendered and the significance of the findings. It is unclear what the Plan contends is missing to validate 
that this testing was performed.  Therefore, we decided that the Plan has to pay for the DecisionDx-SCC 
genetic testing provided on March 24, 2023.   
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy sessions. 
 
You asked the Plan to pre-approve the additional physical therapy sessions. You say that the services are 
medically necessary for the enrollee to continue progress towards returning to their prior level of function. The 
Plan denied your request. The Plan says that the services 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 additional physical therapy sessions. 
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 additional requested therapy is not 
generally accepted as specific and effective therapy for the enrollees condition beyond what was already 
approved. The records do not demonstrate that the unique skills of a professional therapist are required to 
safely and effectively provide treatment, 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 or deliver a program to maintain the enrollee's current condition or to prevent or slow further 
deterioration. The enrollee has had instruction in a home exercise program. The additional sessions cannot be 
recommended 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 additional physical therapy sessions have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 10 additional physical therapy sessions.
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 would benefit from the 
LTACH for continual vent weaning, nutritional support, physical therapy, speech therapy, wound care and 
intravenous medication administration. The Plan denied your request. The Plan says the LTACH services are 
not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility. 
 
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 has been treated for respiratory failure related to opioid overdose requiring intubation. He is receiving appropriate care in current acute care setting as provided by Health Plan. 
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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that you have been having success with 
going to PT and would like to continue to avoid surgery. The Plan denied your request. The Plan says you have 
been instructed in a home exercise program. 
 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 additional PT visits. 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 the additional requested therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. You have had extensive 
therapy for this condition. The requested 18 sessions of additional therapy are not medically necessary. You 
can transition to an independent home exercise program. 
 
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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 18 additional physical therapy (PT) visits.