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

 
We decided that the Plan does not have to pay for the distant site telehealth visit (G2025) provided September 
14, 2022. 
 
You asked the Plan to pay for the telehealth visit. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the provider billed code 
G2025 which is not valid for Mental Health Services when performed at Federally Qualified Health Center 
(FQHC).  
 
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 G2025 is payment for a telehealth distant site service 
furnished by a rural health clinic (RHC) or federally qualified health center (FQHC) only. 
 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 telehealth services. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our reviewer found in this 
case, the claim denied correctly as per Centers for Medicare and Medicaid Services (CMS), payment under 
HCPCS code G2025 will no longer apply to mental health visits furnished via telehealth. This payment policy 
for mental health visits was made permanent for RHCs and FQHCs in the calendar year 2022 physician fee 
schedule final rule. There is a more appropriate code to report for service provided. 
 
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 telehealth services have not been met. Therefore, we decided that the Plan 
does not have to pay for the distant site telehealth visit (G2025) provided September 14, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 87640. We decided that the Plan does not have to pay for 87641 and 
87481.  
 
You asked the Plan to pay for laboratory services (procedure codes 87491, 87640, and 87641) rendered on 
April 20, 2022.. You say that this should be paid for. The Plan says that the denied codes remain not supported. 
 
We decided that the Plan has to pay for 87640.  
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.  
 
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 for CPT 87640. Our reviewer says that CPT code 
87640 is supported. There is documentation of results for this test. Since CPT 87641 was not actually 
performed, this test is supported as separate and distinct. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
87640.  
 
We also decided that the Plan does not have to pay for 87641 and 87481. 
 
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 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 for CPT 87641 and CPT 87481. Our reviewer says that 
CPT codes 87641 and 87481 are not supported. There is no documentation in the record or results for these 
tests, either positive or negative. It cannot be verified that they were performed as billed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87641 and 87481 have not been met. Therefore, we decided that the Plan does 
not have to pay for 87641 and 87481. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve SI joint injection. You say that the enrollee's right hip pain is getting worse. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for this procedure. 
 The Plan follows Medicare rules. Medicare rules state that sacroiliac (SI) joint injections may be covered if 
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 SI joint injection. Our reviewer says 
that the enrollee does not meet criteria for this procedure. Our physician reviewer found there is no physical 
examination of the SI joint and no imaging of the SI joint. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services rendered from November 
26, 2022, to November 28, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the submitted documentation supports observation care. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee presented to the emergency department (ED) with right hand 
numbness and weakness episode that lasted 20 seconds, and fully resolved. The examination revealed no 
neurological deficit or weakness, and the enrollee was alert and oriented. The vitals showed high blood 
pressure but was otherwise stable and the labs were unremarkable. The imaging was negative for acute 
abnormalities. Eliquis was restarted as he had been noncompliant with this prescription. No other events were 
noted at the time of admission. Due to the patient being stable with low complexity, it was not expected that 
they would require hospital care that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital services rendered from November 26, 2022, to November 
28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will receive appropriate level of care in 
an IRF setting. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power operated vehicle (K0806). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you are unable to push a walker 
because it is too heavy, and you have trouble walking with no aid. The Plan denied your request. The Plan says 
the requested PMD is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 power operated vehicle. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the requested mobility 
device is not necessary for MRADLs in your home. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 standard power operated vehicle (K0806).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a digital, binaural hearing aid (V5261) purchased on 
February 2023. 
 
You asked the Plan to reimburse for a digital, binaural hearing aid (V5261) . You say that in the process of the 
plan change, you did not pick up that there was a change in coverage. The Plan denied your request. The Plan 
says this benefit is only covered when services are performed by an in-network provider. The Plan also says 
that the records show no calls from you, nor the providers office were made to obtain eligibility and benefits. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only service is performed by an in-network provider.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say that members will receive a negotiated plan 
discount on hearing aids if they are purchased from the preferred Plan vendor. The Plan contract also says that 
appointments must be scheduled through the Plan hearing vendor. The record shows that the appointment was 
not scheduled through the Plan hearing vendor, nor was the appointment in-network. Based on this 
information, we decided that the Plan's rules for coverage of a digital, binaural hearing aid (V5261)  have not 
been met. Therefore, we decided that the Plan does not have to reimburse for a digital, binaural hearing aid 
(V5261) purchased on February 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array. 
 
You asked the Plan to pre-approve the percutaneous implantation of neurostimulator electrode array. You say 
that you went to pain management and pain medications seemed to be your last hope after everything that has 
been tried. You say that you need this implant to help you function better and maybe get you off fentanyl. The 
Plan denied your request. The Plan says other treatments have not been tried and there is no documentation of 
multidisciplinary team assessment including evaluation by psychology. 
 
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 percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there has been no multi-
disciplinary assessment, no psychological assessment and physical therapy has not been tried. Therefore, the 
NCD criteria has 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 percutaneous implantation of neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous implantation of 
neurostimulator electrode array.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found in this case there are no medical records 
that mention the presence of both AD and FTD. In such a setting, the provision and performance of the 
requested study would not be consistent with the requirements of the NCD. Therefore, this service would not 
be 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87481, 87798, 87641, 87653 
and 87640 provided July 12, 2022, to September 29, 2022.  
 
You asked the Plan to pay for the laboratory services. You say that please review attached requested 
documentation and reprocess your claim for payment. The Plan denied your request. The Plan says services 
considered to be experimental or investigational are excluded from coverage. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had urinary tract infection (UTI) symptoms. Molecular diagnostics are 
significantly more sensitive in detecting urinary bacteria in adults with UTI) than culture. To date, the standard 
of care remains urinalysis and urine culture to diagnose a UTI. The review has determined that the services at 
issue in this case were not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 87481, 87798, 87641, 87653 and 87640 provided July 
12, 2022, to September 29, 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 the continuity of care offered at the IRF will give the 
enrollee the best opportunity to improve function and return to baseline. The Plan denied your request. The 
Plan says the request for 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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 pay for the lower extremity duplex scan provided on February 25, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON imaging interpretation . You say that you are not able to obtain 
authorization prior to rendering the radiology interpretation. You feel this should be covered.  The Plan denied 
your request. The Plan says this was ordered by an OON provider without authorization. As such, the services 
cannot be paid.  
 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 lower extremity duplex scan provided on 
February 25, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 21, 2023. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side. 
 
We looked at 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. This claim was billed with right side diagnosis 
Z96.641 and left side diagnosis Z96.642 which should not be billed together if there is a bilateral diagnosis 
(Z96.643) code available. Therefore, we decided that the Plan does not have to pay for imaging services 
provided on February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment. 
 
You asked the Plan to pay for the oxygen equipment.. You say that the item should be covered. 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. Your 
contract with the Plan says that the enrollee must pay 50% of the Medicare allowed amount after the $950 
deductible for out-of-network durable medical equipment (DME). which applies to durable medical equipment.  
 
The item or service you asked the Plan to pay for falls within the durable medical equipment. benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that the enrollee must pay 50% of 
the Medicare allowed amount after the $950 deductible for out-of-network durable medical equipment (DME) which applies to durable medical equipment. This cost sharing is a contractual obligation that had not been met 
at the time the oxygen equipment. was received on November 21, 2022. Therefore, we decided that the Plan 
does not have to pay for the oxygen equipment.