Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the clinic services provided on February 7, 2023. 
 
You asked the Plan to reimburse you for the clinic services. You say that you presented documentation 
covering the medical expenses and medicines incurred in Chile on February 7, 2023. The Plan denied your 
request. The Plan says the only proof of payment provided by the member was for medications dispensed on 
February 7, 2023, for a total amount of $32.28. No further supporting documents demonstrating proof of 
payment for the amount of $490.75 were provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the emergency department clinic 
services have been met. The file shows that proof of payment was provided. Therefore, we decided that the 
Plan does not have to reimburse you for the clinic services provided on February 7, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 9, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you were not aware this provider was no longer 
participating. The Plan denied your request. The Plan says this provider is not a Medicare-qualified mental 
health care provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program.   
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program.   
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 30, 2022, 
and March 31, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the claims were filed timely. The 
Plan denied your request. The Plan says the claim was received past one year and is considered untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for subsequent nursing facility care was not filed until April 13, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on 
March 30, 2022, and March 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OON provider.  
 
You asked the Plan to pre-approve an MRI of the pelvis. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says the enrollee must receive your care from a network 
provider. 
 
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 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a spine x-ray provided on May 30, 2023. 
 
You asked the Plan to pay for the spine x-ray. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the spine x-ray is not a covered benefit. We cover only manipulation of the 
spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a spine x-ray provided on May 30, 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 will benefit from acute rehabilitation to 
optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that that the requested medication is the best for the 
patient.  The Plan denied your request. The Plan says that the step therapy requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that 
Feraheme is not medically necessary. Our physician reviewer found that the enrollee has an iron deficiency, 
and the requested medication is new start. However, there is no indication that the enrollee has tried and failed 
the Plan's preferred step one alternative. Also, there is no indication that the enrollee has a contraindication to 
or would have an adverse effect from the Plan's preferred step one alternative. Therefore, the elements of the 
coverage criteria are not satisfied, and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an AngelMed Guardian System (0525T, C1833). 
 
You asked the Plan to pre-approve an AngelMed Guardian System. 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 an AngelMed Guardian System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the clinical studies led to FDA approval, the AngelMed Guardian 
system remains the subject of studies assessing long-term efficacy, as well as randomized, controlled, blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the AngelMed Guardian system would not be 
considered medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an AngelMed Guardian System have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an AngelMed Guardian System (0525T, C1833).
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 you are ready to be discharged to the next level of 
care. You say that if you go home you will be at risk for falling. The Plan denied your request. The Plan says 
an IRF admission is not medically necessary.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that  The Plan denied your 
request. The Plan says a CT scan of the abdomen and pelvis is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the abdomen and pelvis. 
Our reviewer says that a CT scan of the abdomen and pelvis is not medically necessary. Our physician reviewer 
found that the enrollee has a pending colonoscopy and a negative chest x-ray on November 10, 2022. 
Therefore, the medical necessity for the CT scan of the abdomen and pelvis has not been established. 
 
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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis.
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 since the enrollee's femur fracture they continue to 
require increased assistance due to being in pain and being fatigue. The Plan denied your request. The Plan 
says an IRF admission is not medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 27, 2023, to 
February 25, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted timely but was 
then rejected. You believe that because the original submission was timely, this claim should be paid. The Plan 
denied your request. The Plan says a valid NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 28, 2022. The NOA was not received by the Plan until February 
27. 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 27, 2023, to February 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 rendered on February 14, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99213-25 (1 Units) remains 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 99213 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 low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records submitted 
didn't include an evaluation and management note. That note is needed to verify that a significant, separately 
identifiable service was performed. Because the note wasn't included, the use of the -25 modifier cannot be 
verified. The review has determined that the documentation did not support procedure code 99213 as a separate 
and distinct evaluation and management service from CPT 20610. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99213 rendered on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic comprehensive preventative exam (code 99397) 
provided on May 4, 2023. 
 
You asked the Plan to pay for the periodic comprehensive preventative exam. You say that this visit was for 
your yearly physical and has been covered in the past years. The Plan denied your request. The Plan says per 
your 2023 benefit plan, a periodic comprehensive preventative exam (code 99397) is not a covered benefit. 
Your benefit plan only covers an annual wellness visit and your provider billed a periodic comprehensive 
preventative exam, therefore the denial is correct. 
 
The Plan contract only covers an annual wellness visit. 
 
We looked at the file and the Plans rules. The file shows that the Plan only covers an annual wellness visit, 
which was not billed by your provider. Therefore, we decided that the Plan does not have to pay for a periodic 
comprehensive preventative exam (code 99397) provided on May 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee suffers from chronic low 
back pain. The Plan denied your request. The Plan says this procedure is not a covered service. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found There is no magnetic resonance imaging (MRI) showing only modic changes without 
facet joint disease or foraminal stenosis. The cause of pain is not clear.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Breast Cancer Index testing (81518) billed for date of service May 
1, 2023. 
 
You asked the Plan to pay for procedure code 81518. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that this claim was submitted with an incorrect 
date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are exceptions to this rule. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Breast Cancer Index testing have been met. Specifically, the records indicate that the specimen in 
this case was breast tissue which would have been collected during a medically necessary hospital encounter. 
The test was performed after discharge. This means that the appropriate date of service to report on this claim 
would have been the date the test was reported, which in this case is May 1, 2023. Therefore, we decided that 
the Plan has to pay for the Breast Cancer Index testing (81518) billed for date of service May 1, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full body PET scan concurrently with a CT scan to be 
provided by an OON provider. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says in-network providers are available. 
 
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 
a full body PET scan concurrently with a CT scan to be provided by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that Eylea is 
not medically necessary. Our physician reviewer found that the enrollee has tributary retinal vein occlusion 
with macular edema. Although the requested medication is a new start, there is no indication that the enrollee 
has tried and failed the Plan's preferred step one alternative. There is no indication that the enrollee has a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative. Therefore, 
the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.