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

 
We decided that the Plan does not have to pay for procedure code 99291 for date of service March 4, 2023. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
 
 We find that CPT code 99291 is not payable as billed. Specifically, this code was billed with diagnosis codes 
(Gross hematuria) and N30.01 (Acute cystitis with hematuria). Due to an Excludes1 note, these two diagnosis 
codes should not be billed together. This means this code is not payable as billed. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99291 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99291 for date of service March 4, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection provided on March 30, 
2023. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that you have never had to pay this 
amount before. 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 20% 
coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the drug injection. This item/service falls within the in-
network Medicare Part B drugs 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. The total you owe is $187.97 ($939.84 allowed amount x 20% coinsurance = 
$187.97). Therefore, we decided that the Plan does not have to waive the coinsurance for the drug injection 
provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dispensing fee provided on May 3, 2023. 
 You asked the Plan to pay for the dispensing fee. You say that you say this should have been covered under 
your plan. You say that the provider stated that they checked on the coverage before ordering the eyewear. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, the service is not listed as a covered benefit. Based on 
this information, we decided that the Plan's rules for coverage of the dispensing fee have not been met. 
Therefore, we decided that the Plan does not have to pay for the dispensing fee provided on May 3, 2023.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pre-approve transcranial magnetic stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. You say that at this time TMS is the best solution for you. The Plan 
denied your request. The Plan says that you do not meet Medicare criteria for TMS. 
 
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. The Plan did not submit any supporting medical records related to your request, 
nor did the Plan submit documented attempts to obtain medical records. We requested medical records, but 
none were sent to us. Without supporting medical records, we cannot determine whether you meet Medicares 
clinical criteria for coverage of TMS. Therefore, the Plan has not shown that its decision to deny authorization 
for this service is medically appropriate or justified according to Medicare rules. Therefore, we decided that the 
Plan has to pre-approve transcranial magnetic stimulation (TMS).  
 
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 reimburse you for the prolotherapy (20999) provided on January 11, 
2023. 
 
You asked the Plan to reimburse you for the outpatient service. You say that this doctor does not take 
insurance. You say that the doctor advised the treatment was medically necessary for your quality of life. You 
also say that you were never told by anyone that you needed prior authorization. The Plan denied your request. 
The Plan says this treatment is not considered proven and therefore is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical effectiveness of prolotherapy, joint 
sclerotherapy, and ligamentous injections with sclerosing agents has not been verified by scientifically 
controlled studies and therefore are not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient service have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the prolotherapy (20999) provided on January 11, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0318 billed for date of service May 10, 2023. 
 
You asked the Plan to pay for procedure code G0318. You say that the bundled payment conflicts with the 
Plan's policies. The Plan denied your request. The Plan says that procedure code 99350 is included in procedure 
code G0318. 
 
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 G0318 is prolonged home or residence evaluation and 
management service(s) beyond the total time for the primary service (when the primary service has been 
selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified 
healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99345, 
99350 for home or residence evaluation and management services). 
 
We find that CPT code G0318 is supported. Specifically, code G0318 is an add-on code that was billed with 
code 99350 as required. Based on this information, we decided that Medicare rules for coverage have been met. 
Therefore, we decided that the Plan has to pay for procedure code G0318 billed for date of service May 10, 
2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service September 13, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the lab reports support medical necessity.  The 
Plan denied your request. The Plan says a panel of tests should be billed under a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that the wound panel test was not billed with a single code as required. 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 panel testing billed for date of service September 13, 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 medical records support the need for IRF 
admission. The Plan denied your request. The Plan says based on Medicare guidelines and the information we 
have about the enrollee's condition they do not meet all of the requirements for IRF admission. 
 
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 is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. No acute rehabilitation nursing needs are 
identified. The complexity of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) 
do not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative 
care. The enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as 
in a skilled nursing facility or in-home with 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 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. The Plan denied your request. The Plan says the enrollee's records 
show the need for physician supervision by a rehabilitation doctor at least 3 days per week. 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support the need for IRF 
admission. The Plan denied your request. The Plan says the required skilled rehabilitation and nursing services 
can be met safely and effectively 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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. No acute rehabilitation nursing needs are 
identified. The complexity of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) 
do not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative 
care. The enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as 
in a skilled nursing facility or in-home with 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the prolotherapy (20999) provided on December 
14, 2022. 
 
You asked the Plan to reimburse you for the outpatient service. You say that this doctor does not take 
insurance. You say that the doctor advised the treatment was medically necessary for your quality of life. You 
also say that you were never told by anyone that you needed prior authorization. The Plan denied your request. 
The Plan says prolotherapy is never covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical effectiveness of prolotherapy, joint 
sclerotherapy, and ligamentous injections with sclerosing agents has not been verified by scientifically 
controlled studies and therefore is not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient service have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the prolotherapy (20999) provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says the facet joint 
injections 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 the injections. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found that there is no documentation 
indication why the enrollee is not a candidate for radiofrequency ablation therapy. Therefore, the enrollee does 
not meet the LCD coverage 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
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 enrollee lives alone with no immediate family 
near and fell last night due to being weak. The enrollee just needs an additional two weeks of rehabilitation to 
regain strength.  The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
admission. 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: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided on December 31, 2022, to January 6, 
2023. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the inpatient hospital care was 
medically necessary. The Plan denied your request. The Plan says that care could have been provided at a 
lower level. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the inpatient hospital care provided. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee required inpatient management of medically complex, 
immediately life-threatening issues such as stercoral colitis and potential sepsis from a gynecologic source, so 
the requested inpatient admission was 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 inpatient hospital care provided have been met. Therefore, we decided that 
the Plan has to pay for inpatient hospital care provided on December 31, 2022, to January 6, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye examination, the visual field examination, the 
ophthalmic diagnostic imaging, and the diagnostic dark adaption examination provided on January 12, 2023. 
provided on January 12, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the vision services. You say that this was follow-up care to cataract surgery 
which was medically necessary. The Plan denied your request. The Plan says the services were not authorized, 
and the provider was out-of-network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 did not pre-approve the 
vision services. We found no exception that would require the Plan to pay for the vison services. Therefore, we 
decided that the Plan does not have to pay for the eye examination, the visual field examination, the ophthalmic 
diagnostic imaging, and the diagnostic dark adaption examination provided on January 12, 2023. provided on 
January 12, 2023, by an out-of-network (OON) provider.
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 the enrollee needs have been met and 
stabilized in the acute care setting and they are stable to transfer to an LTACH for the continuation of care in 
the long-term acute care setting. The Plan denied your request. The Plan says an 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 that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health Plan. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic resonance (eg, proton) imaging, brain 
(70553). 
 
You asked the Plan to pre-approve a Magnetic resonance imaging. The Plan denied your request. The Plan says 
this service is not medically necessary for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 a Magnetic resonance imaging. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the elements of the 
coverage criteria are not satisfied and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Magnetic resonance imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Magnetic resonance (eg, proton) imaging, brain (70553).