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

 
We decided that the Plan does not have to pre-approve ultrasound image guided radiation therapy, also known 
as US-IGRT. (G6001x31). 
 
You asked the Plan to pre-approve IGRT. You say that radiation treatment is your only real option. To make 
certain that the radiation is being directed precisely at the two locations of skin cancer, the Image Guidance 
Radiation Therapy (IGRT) is necessary. If this third round of the malignancy is not properly treated, which is 
likely if the ultrasound is not available, the likelihood of spread is increased. The Plan denied your request. The 
Plan says your doctor requested coverage for a special type of radiation treatment to treat your skin cancer. 
There is not enough evidence that this type of radiation therapy guidance is needed or effective for your skin 
cancer. Therefore, it not considered standard of care. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize 
the target so as to minimize normal tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so 
when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume 
of normal tissues exposed to radiation. Usually, IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to you for which the 
target lesion can be seen on the skin to assist in daily set up. Certainly, using ultrasound on a daily basis is not 
unreasonable to offer but not necessary. The device itself is Food and Drug Administration (FDA) approved for 
use with ultrasound though that in and of itself does not mean that daily imaging is necessary but simply that 
the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or 
IGRT for a technology for which need has not been established by published data or supported by consensus 
guidelines (many of which recommend against treatment with these devices in general) is not necessary. The 
decision is unfavorable as billing for daily IGRT which would not be furnished in accordance with accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve ultrasound image guided radiation therapy, also known as US-IGRT. (G6001x31).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freedom Stimwave PNS device (64555 and L8680) 
 
You asked the Plan to pre-approve the Freedom Stimwave PNS device. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this is considered experimental. 
 
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 the Freedom Stimwave PNS device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental. 
 
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 Freedom Stimwave PNS device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Freedom Stimwave PNS device (64555 and L8680)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mechanical home ventilator (E0466). 
 
You asked the Plan to pre-approve the mechanical home ventilator. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 mechanical home ventilator. Our 
reviewer says that the enrollee does not need this item. Our physician reviewer found the Life2000 system is not a true ventilator because it is not capable of providing full ventilatory support. It is intended to be used 
during activity, and there is inadequate evidence that it is beneficial in the treatment of any chronic lung 
disease.  
 
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 mechanical home ventilator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the mechanical home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
December 08, 2022. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you thought you were 
seeing your primary care provider. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The records show you were seen by a specialist on December 8, 
2022. Therefore, we decided that the Plan does not have to reduce the copayment for the specialist office visit 
provided on December 08, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a periodic comprehensive preventive medicine wellness exam provided 
on January 24, 2023. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine wellness exam. You say that the 
services were medically necessary. The Plan denied your request. The Plan says that a preventive medicine 
service (codes 99381-99397) is a non-covered service. 
 
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. Specifically, the Plan has not provided a valid Medicare rule, a Plan rule or a 
coding rule to substantiate their denial. Therefore, we decided that the Plan has to pay for a periodic 
comprehensive preventive medicine wellness exam provided on January 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 3, 2023, to 
February 27, 2023. 
 
You asked the Plan to pay for the home health services. You say that you billed the NOA on time when the 
enrollee was admitted to your services in November. The Plan denied your request. The Plan says the 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 5, 2022. The NOA was not received by the Plan until April 4, 
2023. As more than 30 days passed since 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 the home health services provided 
from February 3, 2023, to February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says that the facet 
joint injection is not medically necessary.  
 
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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found the enrollee has a history of stage 4 
breast cancer with multiple bony metastases. The enrollee has had C3-4, C4-5, and C5-6 bilateral facet joint 
injections. However, the LCD limits the number of facet joint injections to 2 levels per session. The third level 
exceeds the limits. Therefore, the request is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a facet joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
on February 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that  you are requesting this claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 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 the unlisted molecular pathology procedure 
(81479) provided on February 13, 2023, by an out-of-network (OON) provider.
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 requires close monitoring, 
and that LTACH is the right level of care before transitioning to SNF. The Plan denied your request. The Plan 
says that the enrollee's needs can be met in another 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH 
that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and are able to 
be furnished safely and effectively only on an inpatient basis. 
 
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 pay for procedure code G3002 billed for date of service February 14, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
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 G3002 is Chronic pain management and treatment, 
monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating 
scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan 
that includes strengths, goals, clinical needs, and desired outcomes. Required initial face-to-face visit at least 30 
minutes provided by a physician or other qualified health professional. We find that CPT code G3002 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code G3002 billed for date of service February 14, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) care provided on January 1, 2023, to 
January 6, 2023. 
 
You asked the Plan to pay for SNF care. You say that you disagree with the denial and request reconsideration 
of the denied charges on this claim. The Plan denied your request. The Plan says that the charges submitted by 
this provider exceed the fee schedule/maximum allowable or contracted/legislated fee arrangement. 
 
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. Specifically, the Plan has not forwarded sufficient information to support their 
denial. The documentation submitted does not include any indication as to why payment for the SNF services 
was denied. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan 
did not substantiate their denial so we must find in your favor. Therefore, we decided that the Plan has to pay 
for skilled nursing facility (SNF) care provided on January 1, 2023, to January 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on April 25, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are requesting reconsideration for the denied 
payment. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on April 25, 2023.
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 you are requesting an expedited appeal 
of this decision and have provided clinical documentation to support this request. The Plan denied your request. 
The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting.  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 the services (87631, 99072, 94761) provided on November 
1, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. The rules also say that providers/suppliers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. We also find that procedure code 94761 has a status indicator 
of T on the Physician Fee Schedule. As there are other services payable under the physician fee schedule billed 
on the same date by the same provider, code 94761 is bundled into the physician services for which payment is 
made. Based on this information, we decided that Medicare rules for coverage of codes 99072 and 94761 have 
not been met. Therefore, we decided that the Plan does not have to pay for the services (87631, 99072, 94761) 
provided on November 1, 2022.
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 requesting an expedited appeal for the denial 
of an IRF admission. You say you were independent and active before coming to the hospital, and you want to 
return to being independent. The Plan denied your request. The Plan says you do not meet the Medicare criteria 
for admission to an IRF.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided 
January 10, 2023, to February 28, 2023. 
 
You asked the Plan to pay for the psychotherapy services. You say that this provider is out of network, but the 
enrollee does have out of network benefits.  The Plan denied your request. The Plan says the service was 
rendered by a Licensed Professional Counselor. This provider type is no eligible in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services 
(90837) provided January 10, 2023, to February 28, 2023.