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

 
We decided that the Plan does not have to pre-approve prostatic arterial embolization (PAE). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered an experimental technique. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic 
benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and 
efficacy. The most recent American Urological Association (AUA) guidelines do not recommend this 
procedure outside of a clinical trial setting due to the heterogeneity in the available literature and safety concerns regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, 
higher clinical failure rate compared with more traditional methods (eg, transurethral resection of the prostate 
[TURP]). 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve prostatic arterial embolization (PAE).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy for implantation of neurostimulator 
electrodes, plate/paddle, epidural (63655). 
 
You asked the Plan to pre-approve laminectomy for implantation of neurostimulator electrodes, plate/paddle, 
epidural. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary because records show the enrollee has not had a spinal cord stimulator trial that has been 
effective. The records do not show that a percutaneous stimulator trial is not able to be performed. 
 
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 laminectomy for implantation of 
neurostimulator electrodes, plate/paddle, epidural. Our reviewer says that the enrollee does not meet coverage 
criteria. Our physician reviewer found there must be a trial stimulator period with adequate relief. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laminectomy for implantation of neurostimulator electrodes, plate/paddle, 
epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve laminectomy for 
implantation of neurostimulator electrodes, plate/paddle, epidural (63655).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease in the lumbar spine. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific 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 L2 kyphoplasty. Our reviewer says that 
the enrollee does not meet coverage criteria. Our physician reviewer found there is no documentation of a 
brace. More conservative measures are needed.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22514).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation services.
You asked the Plan to pre-approve ambulance transportation services. You say that you need to be seen by your doctor. The Plan denied your request. The Plan says that ambulance transportation to a physician's office is not a covered location.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for ambulance transportation services. Our Medical Director states that the documentation does not support that ambulance transport was medically necessary for you. The documentation does not support that another means of transport was contraindicated in this case. Our physician reviewer found that your condition does not meet Medicare criteria for ambulance transportation services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation services have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulance transportation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2310) for the enrollee.
You asked the Plan to pre-approve an electronic connection. You say that the requested electronic connection device is medically necessary. The Plan denied your request. The Plan says that there is not a medical need to control the power option through the joystick.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an electronic connection. Our Medical Director states that the documentation supports that the enrollee has upper extremity strength and function that are adequate to control power options using their own switches. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of an electronic connection.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2310) for the enrollee.
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. The Plan denied your request. The Plan says the enrollee does not meet the 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 17, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the type of bill is required on the claim. This four-digit alphanumeric code gives three specific pieces of information after a leading zero. The provider would use code 0 when it does not anticipate payment from the payer for the bill, but is informing the payer about a period of non-payable confinement or termination of care..  
 
We looked at the file and Medicare rules. The provider in this case did not explain why a type of bill was used 
that indicates no payment, and without any explanation, the services cannot be paid. 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 the services provided on January 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services rendered on November 21, 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 records do not clearly document the assistant surgeon's role during the operative session 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 51999. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. 
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
enrollee had benign prostatic hyperplasia, and underwent robotic prostatectomy with cystoplasty on this date of 
service. The request was for coverage of a surgical assistant. The records do not clearly document the assistant 
surgeon's role during the operative session and therefore medical necessity for assistant at surgery has not been 
established. Further, the assistant surgeon's name is handwritten into the operative report following 
transcription. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for assistant surgeon services rendered on November 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services.  

You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. 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 clinical 
documentation does not specify any further home health skilled nursing needs. 
 
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 home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic connection 
device, and newchair occupied transit. 
 
You asked the Plan to pre-approve power wheelchair components. You say that you need this due to a 
traumatic brain injury. The Plan denied your request. The Plan says these components are 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 power wheelchair components. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have use of your upper extremities and can operate and control the 
power options using the switches that are included in the wheelchair base. Additionally, there is no indication 
that the newchair occupied transit would improve your function or general health. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair components have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller, harness, electronic connection device, and 
newchair occupied transit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75774 and 75726 billed for date of service 
November 2, 2022. 
 
You asked the Plan to pay for procedure codes 75774 and 75726. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 75774 and 75726 is bundled into 
payment for code 37243. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that codes 75774 and 75726 are column II codes to column I code 37243. 
While these codes were billed with modifier -59, the medical records provided do not show that the services 
billed with the -59 modifier are distinct procedural services. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 75774 
and 75726 billed for date of service November 2, 2022.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on September 21, 2022.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must be submitted to the primary insurer.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided on September 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 33225, 33249 and 99153 provided on 
October 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for procedure codes 33225, 33249 and 99153. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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. 
 
Furthermore, Medicare rules say that providers must report services correctly. Providers must report services 
with the appropriate CPT code. In this case, we have confirmed that code 99153 is an add-on code and has not 
been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing 
criteria for code 99153 have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 33225, 33249 and 99153 
provided on October 6, 2022, by an out-of-network (OON) provider.
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 due to the complexity of the enrollee's 
condition, continued acute care for an extended period of time is required before a transfer to a lower level of 
care is safe. The Plan denied your request. The Plan says the requested LTACH admission is not medically 
necessary. 
 
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 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 requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting. The health 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2023. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says these services are 
carved out to the County Mental Health Plan (MHPs) as per APL 18-015 and are not included in the capitation 
rate for Medical Care Plans (MCPs). Please refer to the county MHP for payment. 
 
The Plan contract says except for emergency care, you may have to pay for care from providers who are out of 
the network.  
 
We looked at the file and the Plans rules. Based on this information, we decided that Plans rules for coverage 
of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on January 13, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health treatment with a Licensed 
Mental Health Counselor (LMHC). 
 
You asked the Plan to pre-approve outpatient mental health treatment with a LMHC. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient mental health treatment with a LMHC have not been met. Therefore, we decided that the 
Plan does not have to pre-approve outpatient mental health treatment with a Licensed Mental Health Counselor 
(LMHC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on January 09, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. 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 January 09, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystourethroscopy, with biopsy(s) (52204) and 
endoscope (C1747) provided on February 16, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
Code C1747 is a pass-through device code that must be billed with required CPT codes 50575, 50951, 50953, 
50955, 50957, 50961, 50970, 50972, 50974, 50976, 50980, 52344, 52345, 52346, 52351, 52352, 52353, 52354, 
52355, 52356 and C9761. As the claim was not billed with one of the required procedure codes, the claim was 
correctly denied. 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 the cystourethroscopy, with 
biopsy(s) (52204) and endoscope (C1747) provided on February 16, 2023.