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

 
We decided that the Plan has to pay for an outpatient hospital visit on May 30, 2023. 
 
You asked the Plan to pay for the outpatient hospital visit. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that the provider is out-of-network and prior authorization was not obtained. 
 
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. We find that the Plans denial reason is not supported, because the enrollee was 
enrolled in a Preferred Provider Organization (PPO) contract on the date of service, which has out-of-network 
benefits, and they did not give us any other evidence/rationale to support a denial. Additionally, this was an in-
person visit to an outpatient hospital, not a telehealth visit. Therefore, we decided that the Plan has to pay for an 
outpatient hospital visit on May 30, 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 the laboratory services provided on July 14, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that at the time it was necessary to use an out-
of-network provider. 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 laboratory services 
provided on July 14, 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 you are requesting reconsideration based on medical 
necessity. The Plan denied your request. The Plan says the request 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. At the current 
functional level,  the enrollee needs physical and occupational therapy but does not need intensive therapies 
consisting of at least three hours of therapy per day at least five days per week with a multidisciplinary 
approach in an IRF. The enrollees rehabilitation needs can be safely provided in an alternate and low intensity 
setting such as in a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography (93458). 
 
You asked the Plan to pre-approve a cardiac catheterization. You say that the appellant is requesting 
reconsideration stating the enrollee is experiencing shortness of breath with exertion. Patient is at risk of having 
a myocardial infarction. The Plan denied your request. The Plan says the records do not show that it is 
medically reasonable to pursue cardiac catheterization at this time in the work up of the enrollee's problems, 
without other less invasive cardiac testing and evaluation first. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical appropriateness and necessity for performance of cardiac 
catheterization. The enrollee rides bike 20 miles/day and swims 500meters/day, with dyspnea improved since 
recent 20-pound weight loss. The electrocardiogram is not uninterpretable, and he is able to exercise. The 
rationale for this invasive study is not clear. Guidelines do not support a need for cardiac catheterization in this 
setting. As a result, at this time cardiac catheterization would not be considered medically appropriate and 
necessary 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 a cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, including 
intraprocedural injection(s) for coronary angiography (93458).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse in 
the home or hospice setting. 
 You asked the Plan to pre-approve home health services. You say that home health is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve direct skilled nursing services of a registered nurse in the home or hospice setting.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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 appears to be improving with the current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care soon. The enrollee does not require services at the 
LTACH that are not already available. 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 intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that IMRT is medically necessary for this patient. IMRT 
results in more conformal target coverage and normal tissue sparing than 3D conformal radiotherapy. The Plan 
denied your request. The Plan says there is no good evidence that IMRT is needed or effective for the patient'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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from 
high dose exposure. IMRT generally implies inverse planning algorithms, i.e., the physician determines radiation treatment parameters to maximize dose to the target and minimize dose to normal tissues, and the 
planning algorithm maximizes the adherence to these parameters by modifying the beam spatially and/or 
temporally.  This patient is being offered palliative radiation to the sacral area. Prior radiotherapy was to a 
completely different site (thorax) for which cumulative/composite doses would not be relevant. IMRT for bone 
metastases is uncommonly needed for the palliative treatment. For this case, there is no dosimetric rationale for 
IMRT or plausible explanation for why IMRT would be needed over 2D or 3D radiation. IMRT can be 
considered medically necessary (even for palliation and/or non-standard indications) when justified by 
quantitative dose measures- when the dose-volume exposure of critical structures in unacceptable without 
IMRT.  In addition, 20 fraction of radiation for palliation is not standard.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity-modulated radiation therapy (IMRT).
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says admission to an LTACH does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with acute hypoxic and hypercapnic respiratory failure in 
the setting of sepsis secondary to Mycoplasma pneumonia. The record indicates that the enrollee has ongoing 
medical issues and still requires acute care services before transitioning to a lower level of care. The enrollee 
continues to receive acute care services, and these have not been denied. The medical record does not indicate 
that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 
facility. The elements of the coverage rules are not satisfied. 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 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 practitioner services provided on July 27, 2023, billed with 
code K1034. 
 
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 this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that effective May 12, 2023, COVID-19 over the 
counter (OTC) tests are no longer a covered benefit for Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on July 27, 2023, billed with code K1034.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve oncology care. You say that you have not seen your treating physician and 
no one answers your contact attempts. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan and you can be treated 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 
oncology care to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary. The 
Plan denied your request. The Plan says this device is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory testing to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve lab test. You say that you have not been able to get the tests that you need. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and the needed 
testing can be performed 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 
laboratory testing to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service May 12, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the biopsy and pathology service were performed 
by two different providers. The Plan denied your request. The Plan says the appropriate code was not billed. 
 
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 88305 is a level IV surgical pathology exam. We find 
that CPT code 88305 is not supported in the medical record. Surgical pathology of a prostate needle biopsy 
specimen should be reported with code G0416. Based on this information, we decided that Medicare rules for 
coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88305 billed for date of service May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822, 95861, and 95999 rendered on June 
6, 2022. 
 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 the denied codes remain 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 the denied codes is: 
 
CPT 95822: 
 
Electroencephalogram (EEG); recording in coma or sleep only 
 
CPT 95861: 
 
Needle electromyography; 2 extremities with or without related paraspinal areas 
 
CPT 95999: 
 
Unlisted neurological or neuromuscular diagnostic procedure 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support that the codes were performed as billed. CPT 95822 is not supported. THe record states that an EEG 
was performed for intraoperative monitoring. There is a more specific code to report this procedure. CPT 
95999 is not supported. The record does not support that an unlisted procedure that is not reportable with an 
existing CPT code was performed. 2 units of CPT 95861 are not supported. The record states that lower EMG 
was performed only, which equals 1 unit. 
 
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 codes 95822, 95861, and 95999 rendered on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service June 5, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the code at issue is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is: Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, the code definition is time-based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99233 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99233 billed for date of service June 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053, 83540, 84550, 85652, and 85025 for 
date of service March 21, 2023. 
 
You asked the Plan to pay for procedure codes 80053, 83540, 84550, 85652, and 85025. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the claim does not match the 
medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT codes 80053, 83540, 84550, 85652, and 85025 are not payable as billed. Specifically, the 
medical records submitted reference a Clinical Laboratory Improvement Amendments of 1988 (CLIA) and the 
claim form references a different CLIA. This means where the billed services were performed cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of procedure codes 80053, 
83540, 84550, 85652, and 85025 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 80053, 83540, 84550, 85652, and 85025 for date of service March 21, 2023.