Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the abdominal and pelvic computed tomography (CT) scan 
without contrast.  
 
You asked the Plan to pre-approve the abdominal and pelvic CT scan. You say that the CT is medically 
necessary for chronic pain.  The Plan denied your request. The Plan says that the abdominal and pelvic CT scan 
is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 abdominal and pelvic CT scan. Our 
reviewer says that this service is medically necessary. Our physician reviewer found the enrollee presented 
with chronic right lower quadrant pain. The record shows persistent lower abdominal pain even after negative 
ultrasound studies provides indication for the requested CT of the abdomen and pelvis. 
 
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 abdominal and pelvic CT scan have been met. Therefore, we decided that 
the Plan has to pre-approve the abdominal and pelvic computed tomography (CT) scan without contrast.   
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy services provided on 
April 24, 2023, to April 28, 2023. 
 
You asked the Plan to waive the copayment for occupational therapy services. You say that you were unaware 
a prior authorization was needed. 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 $125 
copayment for outpatient thereapy. 
 
You have been asked to pay a $125 copayment for occupational therapy services. This item/service falls within 
the outpatient thereapy 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 
occupational therapy services provided on April 24, 2023, to April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary suspensory bag (A5105), urinary catheter 
(A4543), drainage bag (A4358), and nurse service (99199), provided on April 19, 2023. 
 
You asked the Plan to pay for the urinary suspensory bag, catheter, drainage bag, and. You say that the items 
were medically necessary. The Plan denied your request. The Plan says these items were obtained through a 
provider that is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the urinary suspensory bag (A5105), 
urinary catheter (A4543), drainage bag (A4358), and nurse service (99199), provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223 billed for date of service May 24, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was placed in observation while in 
the emergency department. The Plan denied your request. The Plan says that an incorrect place of service was 
billed. 
 
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. 
 
We looked at the file and the rules. The claim shows that pace of service code 23 was billed. The rules do not 
disallow payment for the evaluation and management code when reported in the emergency department. The 
medical records provided confirm the services were provided within the emergency department. Based on this 
information, we decided that the Medicare rules for coverage have been met. Therefore, we decided that the 
Plan has to pay for procedure code 99223 billed for date of service May 24, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transperineal placement of biodegradable material, peri-
prostatic, single, or multiple injection(s), including image guidance, when performed (55874). 
 
You asked the Plan to pre-approve hydrogel injection. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the request is not medically necessary because 
there is little evidence in the medical literature to suggest that this is a safe and effective. 
 
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 hydrogel injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found SpaceOAR is covered when specific criteria are met. The records submitted do not 
have enough information to confirm coverage. Polyethylene-glycol (PEG) hydrogel is covered ONCE in 
enrollees with clinically localized prostate cancer with specific criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hydrogel injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve transperineal placement of biodegradable material, peri-prostatic, single, or multiple 
injection(s), including image guidance, when performed (55874).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99490 billed for date of service May 31, 
2023. 
 
You asked the Plan to pay for the billed services. You say that you were the only provider available to do this 
service. The Plan denied your request. The Plan says only 1 practitioner can furnish and bill this service. 
 
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 99490 is chronic care management services with the 
following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or 
until the death of the patient, chronic conditions that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, 
revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health 
care professional, per calendar month. We find that CPT code 99490 is not supported. The enrollees claim information shows that code 99490 was 
billed by a separate provider and paid by the Plan. Code 99490 is not payable more than once on this date of 
service. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99490 billed for date of 
service May 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the CMS 
established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says 
criteria for admission to the LTACH have 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 is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 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 Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on July 14, 2023. 
 
You asked the Plan to pay for physical therapy services. You say that the documents submitted support these 
services provided. 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 physical therapy 
services provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological and neuropsychological tests. 
 
You asked the Plan to pre-approve psychological and neuropsychological tests. You say that it is medically 
necessary. The Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if the total time for the tests exceeds eight hours, a 
report may be requested asking for the medical necessity of the extended testing. 
 
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 epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the provider has 
documented the testing requested and has clearly outlined the need for 8 hours (12 units). The request for 8 
hours (12 units) of testing is approved as medically necessary. There is no documentation why this extended 
testing time is medically necessary. Therefore, this request, for an additional 3 hours (5 units) of testing, is not 
reasonable or necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve psychological and neuropsychological tests.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on June 13, 2022, to July 
01, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that you are requesting a reconsideration of 
the denied claims. 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 physical therapy 
services provided on June 13, 2022, to July 01, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not have complex rehab, medical, and nursing 
needs. The Plan says services may be provided at 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005). 
 
You asked the Plan to pre-approve an ultralightweight wheelchair. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ultralightweight wheelchair. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a medical history of weakness, difficulty ambulating with 
unsteady gait and impaired ability to transfer is functionally non-ambulatory and currently has a standard 
lightweight manual wheelchair for assistance with mobility. The enrollee cannot functionally ambulate with a 
cane or walker and is it risk for falling. The enrollee requires a manual wheelchair for mobility in performing 
daily activities. However, the mobility evaluation indicates that the enrollee currently has a lightweight manual 
wheelchair. There is a lack of documentation supporting that an ultralightweight manual wheelchair would 
significantly increase the enrollee's level of independence in terms of mobility and performing daily activities. 
An alternative seat cushion can be utilized for improved seating and pressure relief. Therefore, the enrollee 
does not meet criteria for the requested item. 
 
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 ultralightweight wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an ultralightweight wheelchair (K0005).
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee can safely receive the care they 
need in the hospital setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. 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 they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied.   
 
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: 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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the criteria for approval of 
an LTACH admission.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate at 
this time. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC) (K0862) and related 
accessories (E0953, E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2323, E2363, E2377, E2609, 
E2617, K0040, K0108). 
 
You asked the Plan to pre-approve a PWC and related accessories. You say that the items should be covered. 
The Plan denied your request. The Plan says this is not covered for the enrollee's place of residence. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a PWC and related accessories is being requested for use in a SNF or hospital. Therefore, 
we decided that the Plan does not have to pre-approve a power wheelchair (PWC) (K0862) and related 
accessories (E0953, E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2323, E2363, E2377, E2609, 
E2617, K0040, K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy billed for dates of service June 8, 2023, 
to June 30, 2023. 
 
You asked the Plan to pay for the billed services. You say that you were compliant with coding guidelines. The 
Plan denied your request. The Plan says the claim was not billed with the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim shows that claim line 1 billed CPT code 97110 with modifier 
GCQ. The CQ modifier must be paired to the GP therapy modifier and the CO modifier with the GO therapy 
modifier. Claims not so paired will be rejected/returned as unprocessable. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the physical therapy billed for dates of service June 8, 2023, to June 30, 2023.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 6 of the requested 16 PT visits. We decided that the Plan does not 
have to pre-approve 10 of the requested 16 PT visits.  
 
You asked the Plan to pre-approve 16 physical therapy (PT) visits.. You say that the services are medically 
necessary. The Plan says that the enrollee has reached a plateau in their treatment and have no medical need to 
continue a professionally supervised maintenance program on an ongoing basis. 
 
We decided that the Plan has to pre-approve 6 of the requested 16 PT visits. We also decided that the 
Plan does not have to pre-approve 10 of the requested 16 PT 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.