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

 
We decided that the Plan does not have to pre-approve a second opinion for neurosurgery with an out-of-
network (OON) provider located in Florida.  
 
You asked the Plan to pre-approve the OON second opinion in Florida. You say that you can't see your original 
orthopedic surgeon since he has left his practice in Buffalo and set-up practice in Florida. You say that he has 
an agreement with his partner, where the partner cannot see his patients. You say that you are getting a first 
opinion on orthopedic surgery and a second opinion on neurosurgery because they have different procedures 
when it comes to surgery. You say that you are trying to prolong any kind of surgery by means of alternative 
solutions.  The Plan denied your request. The Plan says the criteria for out-of-area coverage have not been met.  
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The services in dispute are not emergent in nature and are not 
considered urgent because their need is foreseen prior to leaving the service area. In addition, the Plan has 
network providers available in the area who can provide the items/services at issue in this appeal. Based on this 
information, we decided that Medicare rules for coverage of the OON second opinion in Florida have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a second opinion for neurosurgery with 
an out-of-network (OON) provider located in Florida.
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. The Plan denied your request. The Plan says the enrollee does not 
have complex nursing or medical needs requiring a resource intensive inpatient hospital setting. Services 
needed may be provided safely in a lower level of care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 inpatient rehabilitation admission is medical 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not have complex 
nursing or medical needs requiring a resource intensive inpatient hospital setting. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two physical therapy visits. We also decided that the Plan does not 
have to pre-approve eight physical therapy visits.  
 
You asked the Plan to pre-approve additional physical therapy visits. You say that additional physical therapy 
is medically necessary. The Plan denied your request. The Plan says that the requested additional therapy is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We decided that the Plan has to pre-approve two physical therapy visits.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that two physical therapy visits are medically necessary. Our physician reviewer found that it is reasonable for 
the enrollee to have two of the requested therapy sessions to review a home exercise program that the enrollee 
can perform independently. 
 
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 therapy services have been met. Therefore, we decided that the Plan has to 
pre-approve two physical therapy visits.  
 
We also decided that the Plan does not have to pre-approve eight physical therapy visits. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that eight physical therapy visits are not medically necessary. Our physician reviewer found the records do not 
demonstrate that the unique skills of a professional therapist are required to provide treatment safely and 
effectively, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist for the eight remaining requested therapy sessions. The enrollee has had extensive 
prior therapy for this condition. The requested services are not medically necessary as part of a maintenance 
program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight additional physical therapy visits. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 62323 billed for date of service January 3, 2023. 
 
You asked the Plan to pay for code 62323. You say that this claim is for the physician.  The claim in process is 
for the facility. The Plan denied your request. The Plan says payment for this code is bundled into the global 
surgical package. 
 
The Plan must follow Medicare rules. Medicare rules say when paying for surgeries, the payment includes 
payment for services related to the surgery when furnished by the physician who performs the surgery during 
the postsurgical period.  Depending on the surgery, that postsurgical period can be 0, 10, or 90 days.  Services 
unrelated to the surgery can be paid separately, however, an appropriate modifier must be appended to indicate 
this. 
 
 In this case, you billed code 62323 during the postsurgical period for code 27279.  The claims history shows 
that code 62323 was not billed with any modifier.  Until and unless such a modifier is billed, payment for this 
code is considered part of the global surgical package and separate payment cannot be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 62323 have not been met. Therefore, we decided that the Plan does not have to pay for code 
62323 billed for date of service January 3, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for remote physiologic monitoring treatment management services 
provided on October 30, 2022. 
 
You asked the Plan to pay for the remote physiologic monitoring treatment management services. You say that 
this service is covered by Medicare and is medically necessary. The Plan denied your request. The Plan says 
that the procedure exceeds maximum number of services allowed for a single date of 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 Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for remote physiologic 
monitoring treatment management services provided on October 30, 2022.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on January 3, 2020. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
claim was filed 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 the emergency department visit was not filed until September 17, 2021. 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 an emergency department visit provided on 
January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
October 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel rendered on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program provided on 
January 11, 2023 
 
You asked the Plan to waive the copayment for the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program. You say that according to your 
policy, you should not have to pay for this exam. 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 $25 
copayment for vision care, Medicare covered vision services.  
 You have been asked to pay a $25 copayment for the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program. This service falls within the 
vision care, Medicare covered vision 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. Therefore, we decided that the Plan does not have to waive the copayment 
for ophthalmological services: medical examination and evaluation, with initiation or continuation of 
diagnostic and treatment program provided on January 11, 2023
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring provided on 
August 31, 2022. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that the 
services are covered by Medicare and were medically necessary. The Plan denied your request. The Plan says 
that this service does not meet the coverage requirements in the applicable Local Coverage Determination 
(LCD) or National Coverage Determination (NCD). Related services performed in connection with the denied 
procedure are also not covered.  
 
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 Medicare rule or a coding rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for continuous intraoperative 
neurophysiology monitoring provided on August 31, 2022.  
 
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  Barostim Neo carotid sinus baroreflex device (0266T, 
C1825). 
 
You asked the Plan to pre-approve the Barostim device. You say that you ask that the denial be reviewed and 
the request be approved. The Plan denied your request. The Plan says this device is considered experimental 
and investigational and is still being studied as there is lack of evidence in its safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Barostim device have not been met. Therefore, we decided that the Plan does not have to pre-
approve  Barostim Neo carotid sinus baroreflex device (0266T, C1825).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 0326U for date of service 
October 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary and is a 
covered benefit. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier. 
 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. 
 
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 lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 0326U 
for date of service October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 29580 billed for date of service February 23, 2022. 
 
You asked the Plan to pay for code 29580. You say that this service should be paid because you appended the 
59 modifier.  The Plan denied your request. The Plan says no separate payment is made for this service because 
it is part of the global surgical period. 
 
The Plan must follow Medicare rules. Medicare rules say that when paying for surgeries, the payment includes 
payment for services related to the surgery when furnished by the physician who performs the surgery during 
the postsurgical period.  Depending on the surgery, that postsurgical period can be 0, 10, or 90 days.  Services 
unrelated to the surgery can be paid separately, however, an appropriate modifier must be appended to indicate 
this. 
 
 In this case, you billed code 29580 (Unna boot strapping) during the postsurgical period for code 28090.  
Although you said that you appended the 59 modifier to indicate that code 29580 was separate, this is not true.  
The claims history shows that code 29580 was not billed with any modifier.  Until and unless such a modifier is 
billed, payment for this code is considered part of the global surgical package and separate payment cannot be 
made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 29580 have not been met. Therefore, we decided that the Plan does not have to pay for code 
29580 billed for date of service February 23, 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 services are medically necessary for the enrollee 
to regain their maximum function.  The Plan denied your request. The Plan says the enrollee does not require 
complex medical management such as extensive wound care or high-risk medication changes. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint injections. 
 
You asked the Plan to pre-approve paravertebral facet joint injections. You say that you need these injections to 
prevent surgery. The Plan denied your request. The Plan says the requested paravertebral facet joint injections 
do not meet the Medicare LCD coverage guidelines.  
 
The Plan follows Medicare rules.  
 
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 paravertebral facet joint injections. Our 
reviewer says that the requested paravertebral facet joint injections are not considered medically necessary in 
this case. Our physician reviewer found that you had L4-S1 facet injections on November 28, 2022, and 
December 29, 2022, with a "favorable outcome". You are taking Ibuprofen for pain. You also have an  
L1 vertebral body fracture. There is inadequate documentation to support further injections and there is no 
explanation of why you are not a candidate for RFA. 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 paravertebral facet joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve paravertebral facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99360 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code 99360. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says the billed code is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99360 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code 99360 is not a payable code. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99360 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99360 billed for date of service December 5, 2022.