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

 
We decided that the Plan does not have to pre-approve an MRI of the breast. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee requires annual breast MRI's due to their 
high risk of recurrence. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 pre-approve the MRI. Our reviewer says that an 
annual breast MRI is covered for certain high-risk patients. There are no clinical records provided that indicate 
that the enrollee has a high-risk disease. A history of a triple negative breast cancer does not fit this criteria. 
Therefore, the criteria for coverage have not been met. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the breast.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 10, 2023, billed with 
code 93931. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says a covered diagnosis has not been billed with this 
service. 
 
Medicare rules say that services billed must meet the associated diagnosis code relationship criteria Centers for 
Medicare and Medicaid Services LCD Guidelines. 
 
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 imaging services provided. Our reviewer says that documentation does not support the billed code Our physician reviewer found that per the LCD, a 
covered diagnosis was not reported with this service. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on February 10, 2023, billed with code 93931.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services billed with code J3490 on February 13, 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. Medicare rules say that intra-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 is related to and billed on the same day as 
minor surgical procedure 64483. Payment for code J3490 is included in the global surgical payment for code 64483. Therefore, we decided that the Plan does not have to pay for the drug services billed with code J3490 on February 13, 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 multidisciplinary team is essential to identify and 
establish a base functional platform that will aid the enrollee in recovery. The Plan denied your request. The 
Plan says the enrollee can safely receive the services needed in another setting such as a skilled nursing facility, 
home with home health services or home with outpatient therapy.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 6-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to an 
appointment. The Plan denied your request. The Plan says you have exhausted your transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 6 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
6-trip limit.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 6 additional physical therapy visits. We decided that the Plan does 
not have to pre-approve 18 additional physical therapy visits.  
 
You asked the Plan to pre-approve 18 additional physical therapy visits. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan says that 18 additional physical therapy 
visits are not medically necessary. 
 
We decided that the Plan has to pre-approve 6 additional physical therapy visits.  
 
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 24 additional physical therapy visits. 
Our reviewer says that 6 additional physical therapy visits is medically necessary. Our physician reviewer 
found that the enrollee has a degenerative disease of the cervical spine with neck pain as well as new findings 
of brain lesions on the magnetic resonance imaging. Due to this new condition the enrollee would benefit from 
physical therapy. The enrollee can attend 18 sessions of physical therapy and then be re-evaluated if further 
therapy is required based on their progress. Therefore, 6 additional visits in addition to the 12 already approved 
can be considered medically necessary and the additional 18 visits requested are not necessary without 
demonstrated objective improvement with 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 6 additional physical therapy visits have been met. Therefore, we decided that 
the Plan has to pre-approve 6 additional physical therapy visits.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says the requested item is is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician 
reviewer found that you have chronic obstructive pulmonary disease (COPD) and are on continuous 
oxygen. There is no documentation that oxygen saturation (SpO2) can be maintained above 91% using an 
oxygen conserving device and a flow rate of 1 to 4 L/min as required for coverage. 
 
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 portable oxygen concentrator have not been met.  Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance; cervical or thoracic, single facet joint (64633) and destruction by neurolytic 
agent, paravertebral facet joint nerve(s), with imaging guidance; cervical or thoracic, each additional facet joint 
(64634). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the enrollee has already undergone, and the provider 
has been reimbursed, for two cervical region radiofrequency sessions within the last rolling 12 months. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months. 
 
We looked at the file and Medicare rules. Medicare rules say no more than two radiofrequency sessions will be 
allowed per rolling 12 months. The records show that the enrollee received two cervical region radiofrequency 
sessions on November 4, 2022, and November 18, 2022, therefore, the request exceeds the two sessions 
allowed for reimbursement by the Plan. Based on this information, we decided that Medicare rules for coverage 
of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; cervical or thoracic, 
single facet joint (64633) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance; cervical or thoracic, each additional facet joint (64634).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99245 and 99072 billed for date of service 
March 17, 2022. 
 
You asked the Plan to pay for procedure codes 99245 and 99072. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99245 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99245 is not valid for Medicare purposes. Procedure code 99072 has a Status Indicator of B on 
the Physician Fee Schedule. This means that procedure code 99072 is always bundled for payment and is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of procedure codes 
99245 and 99072 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 99245 and 99072 billed for date of service March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation service and an ultrasound provided on 
September 6, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an evaluation service and an ultrasound. You say that this was a follow-up visit. 
The Plan denied your request. The Plan says this was 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 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 an evaluation service and an ultrasound provided 
on September 6, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2335) for tooth #8 provided on 
January 10, 2023. 
 
You asked the Plan to pay for the dental service. You say that the filling was not cosmetic and it should be 
covered as a necessary repair. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the resin-based composite is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for a resin-
based composite (D2335) for tooth #8 provided on January 10, 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 
December 20, 2022. 
 
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 are 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 December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. 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 cardiac event monitors are 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical necessity for insertion of an implantable cardiac monitor (ICM) in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polyethylene-glycol (PEG) hydrogel spacer. 
 
You asked the Plan to pre-approve a PEG hydrogel spacer. 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 polyethylene-glycol (PEG) hydrogel is 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 PEG hydrogel spacer. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee does not meet the 
coverage criteria detailed in the LCD for a polyethylene-glycol (PEG) hydrogel spacer. Specifically, the 
records show that the enrollee has unfavorable intermediate risk group prostate cancer, and the LCD requires 
favorable intermediate prostate cancer risk group for coverage. 
 
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 PEG hydrogel spacer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a polyethylene-glycol (PEG) hydrogel spacer.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient psychiatric hospital services provided from December 31, 
2022, to January 12, 2023.  
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that it was imperative that the 
enrollee receive services in a timely manner to prevent any adverse outcomes. You also say that the admission 
was medically necessary.  The Plan denied your request. The Plan says that prior authorization was not 
obtained. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
reviewer says that the inpatient psychiatric hospital admission was medically necessary. Our physician 
reviewer found the provided documentation does not indicate the enrollee was showing any dangerousness to 
self or others, the enrollee did have auditory no visual hallucinations, was without aggressive behaviors and no 
acute threats of safety. The reviewer found that the enrollee did require inpatient mental health treatment 
beyond the dates in question as noted above as although he was not a danger to himself or others, he did have 
any delusions, auditory no visual hallucinations. It did appear that active treatment was taking place beyond the 
date in question. It did appear that the services for the dates in question were reasonably expected or medically 
necessary to improve the enrollees condition or for the purpose of diagnosis. It appears that the services were 
supervised and evaluated by a physician. Therefore, the reviewer found that the inpatient admission was 
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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for the inpatient psychiatric hospital services provided from December 31, 2022, to 
January 12, 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 pay for physical therapy services provided from September 23, 2022, 
to September 29, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for physical therapy services. You say that this should be covered. The Plan denied 
your request. The Plan says this was 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 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 physical therapy services provided from 
September 23, 2022, to September 29, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on November 28, 2022, billed 
with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, 
and 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 The Plan must follow Medicare rules. The rules say that a panel cannot be unbundled and billed as individual 
components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on November 28, 2022, billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 
87591, 87641, 87651, 87653, 87661, and 87798.