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

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits that are out-
of-network. 
 You asked the Plan to pre-approve the out-of-network therapy services. You say that the out-of-network PT 
visits are medically necessary. The Plan denied your request. The Plan says the requested PT visits are out-of-
network and can be approved in-network.  
 
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 medical records provided did not show the necessity of out-of-
network PT visits over an in-network provider. Therefore, the enrollee should seek the requested services in-
network. 
 
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 12 additional physical therapy (PT) visits that are out-of-network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left ventricular assist device (LVAD) supplies to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve LVAD supplies. You say that the supplies from other providers do not meet 
your needs. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and the 
needed supplies can be obtained within the Plan network. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
left ventricular assist device (LVAD) supplies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy. 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this is not considered the standard of care for treatment of 
the enrollee's type of cancer. 
 
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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a lack of demonstration for the need of superficial radiation. Superficial 
radiation would not be a standard treatment for this enrollee and guidelines caution against its use versus more 
standard radiation therapy approaches. There are no compelling reasons offered for why superficial radiation would be needed over more standard approaches of radiation delivery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair with multiple power options. You say that the 
enrollee has trialed all the least costly alternatives. You say that the enrollee is unable to ambulate throughout 
their home. You say that the enrollee lives alone and requires assistance for all MRADL's. You also say that the 
power options are necessary for pressure relief, repositioning, and catheterization. The Plan denied your 
request. The Plan says the enrollee does not have a diagnosis that necessitates a Group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 power wheelchair with multiple power 
options may be covered when certain 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 a Group 2 power wheelchair with 
multiple power options. Our reviewer says that the request for a Group 2 power wheelchair with multiple 
power options is not medically necessary. Our physician reviewer found the enrollee is non-ambulatory and 
cannot use a cane or walker for mobility. The enrollee cannot functionally propel a manual wheelchair due to 
upper extremity weakness and impaired shoulder range of motion. The enrollee cannot operate a power scooter 
due lack of accessibility in the home. The reviewer found that the enrollee requires a power wheelchair for 
mobility and accomplishing his daily activities. However, the clinical documentation is insufficient why the 
enrollee requires power tilt and recline. The enrollee is noted to have pain with pressure relief but can perform 
it. The enrollee can perform transfers and does not have a history of skin breakdown. It is also unclear why 
power elevating leg rests are required as the enrollee does not have lower extremity edema or spasticity. 
Therefore, the reviewer found that the requested Group 2 power wheelchair 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 a Group 2 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with multiple 
power options and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 22, 2023, billed with 
procedure codes 99215-25 and 73040-LT. 
 
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 documentation does not support the billed codes. 
 
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 99215-25 and 73040-LT is office or other outpatient 
visit for the evaluation and management of an established patient, which requires a medically appropriate 
history and/or examination and high level of medical decision making. When using time for code selection, 40-
54 minutes of total time is spent on the date of the encounter, and radiologic examination, shoulder, 
arthrography, radiological supervision and interpretation. 
 
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 
documentation does not support the billed codes. Our reviewer found that the enrollee is a 94-year-old male 
who was treated on May 22, 2023. The provided documentation from this date describes the enrollee with right 
knee pain. The history and physical were appropriate, however, the documentation did not support a high level 
of decision-making nor was there a documented duration of the encounter documented to support the code, 
99215-25. X-ray of the left shoulder was performed. However, the arthrogram findings were not described in 
the documentation as required to justify the code, 73040 LT.  
 
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 May 22, 2023, billed with procedure codes 
99215-25 and 73040-LT.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on May 12, 2023, billed with 
procedure code 88305. 
 You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid principal 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say to sequence first the diagnosis, condition, problem, or 
other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient 
services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be 
sequenced as additional diagnoses. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing services provided have not been met. We have found that the claim was billed with 
principal diagnosis code R85.7, which is an inappropriate principal diagnosis in this case. Therefore, we 
decided that the Plan does not have to pay for testing services provided on May 12, 2023, billed with procedure 
code 88305.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 20, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 4, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 23, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service May 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 18, 
2023, to May 17, 2023. 
 You asked the Plan to pay for SNF care. You say that the SNF services provided were medically necessary. 
The Plan denied your request. The Plan says the skilled services could have been provided on an intermittent 
outpatient basis, in a long-term care facility, or at the home with home health care services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided, the enrollee did not qualify for SNF 
coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented 
skilled therapy needs. Daily skilled services are not shown to have been required to establish a maintenance 
program or to prevent deterioration of the enrollee's 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 18, 2023, to May 17, 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 is a fall risk and is unable to 
walk. You say the enrollee needs assistance with daily living. The Plan denied your request. The Plan says 
admission to an LTACH is not medically necessary.  
 
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 there are no required medical services identified that are available at the LTACH 
that are not available at the current health care setting being offered by the Plan. In addition, the documentation 
does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure (22612, 22840). 
 
You asked the Plan to pre-approve a Minuteman procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft 
material and is not intended for stand-alone use. In addition, there are multiple alternate pain generators 
plausibly significantly contributing to the clinical condition that have not been fully documented as having been excluded and/or ruled out. No compelling rationale is presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Minuteman Procedure at 
L4-5 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 a Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure (22612, 22840).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for home visits provided from June 6, 2022, to 
August 28, 2022.  
 
You asked the Plan to reimburse you for the home visits. The Plan denied your request. The Plan says custodial 
care is not a covered under any condition. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home visits have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to reimburse you for home 
visits provided from June 6, 2022, to August 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an epidural steroid injection provided on July 3, 2023. 
 
You asked the Plan to pay for the epidural steroid injection. You say that the epidural steroid injection was 
medically necessary. The Plan denied your request. The Plan says that the epidural steroid injection does not 
meet the Medicare coverage criteria. 
 
The Plan follows Medicare 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 epidural steroid injection. Our reviewer 
says that the epidural steroid injection is considered medically reasonable and necessary in this case. Our 
physician reviewer found the code, 62320-59, billed for the postoperative pain management/anesthesia services 
provided, was appropriate. The anesthesia coding for the procedures appear to be appropriately billed by the 
anesthesiologist. The anesthesiology record supports the billing of code 62320-59.  
 
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 epidural steroid injection have been met. Therefore, we decided that the 
Plan has to pay for an epidural steroid injection provided on July 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service February 10, 
2023.  
 
You asked the Plan to pay for procedure code 88374. You say that you disagree with the Plan's denial. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service February 10, 2023.