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

 
We decided that the Plan does not have to pay for a positron emission tomography/computed tomography 
(PET/CT) scan rendered on January 4, 2023. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says an appropriate diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the enrollee had 
PET/CT on January 4, 2023, with a stated history of "restaging esophageal carcinoma." There is no cell type presented, and no location of the prior tumor within the esophagus. There are no prior imaging reports, 
although the report describes comparison to prior CT of January 5, 2022, and other studies. While esophageal 
carcinoma is a valid indication for PETCT the submitted records are incomplete in order to evaluate medical 
necessity.  In addition, Medicare requires more specific information for billing such as cell type, date of 
original diagnosis etc.  The medical necessity of the PET/CT was not established in the submitted records. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a positron emission tomography/computed tomography (PET/CT) scan rendered on January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 67041 and 67108 provided on December 
19, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure codes 67041 and 67108. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for procedure codes 67041 and 67108 provided on 
December 19, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anticoagulant management provided on March 28, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for anticoagulant management. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for anticoagulant management provided on March 28, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services billed with secondary diagnosis code J96.21 
rendered from June 29, 2022, to July 2, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. 
The Plan says that the determination to remove secondary diagnosis code J96.21 - acute and chronic respiratory 
failure with hypoxia - remains upheld. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 177 and diagnosis code J96.21. 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 services at the DRG originally billed. 
Our reviewer says that the services at issue in this case were supported by the medical records. Our physician 
reviewer found that the records support the diagnosis code of J96.21, as the enrollee has chronic respiratory 
failure but was hospitalized with an acute exacerbation. The records therefore do support hypercapnic 
respiratory failure and DRG 177. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services billed with secondary diagnosis code J96.21 rendered from June 29, 2022, to July 2, 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: 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
Our physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested services 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic endplate changes and no 
facet degenerative joint disease or foraminal stenosis. The cause of back pain is not clear. 
 
   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on March 08, 2023. 
 
You asked the Plan to pay for the office visit (99212). You say that the service was medically necessary. 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 office visit (99212) 
provided on March 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafts (D7953 x2). 
 
You asked the Plan to pre-approve bone grafts. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the requested services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
grafts (D7953 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields. 
 
You asked the Plan to pre-approve ultrasonic guidance for placement of radiation therapy fields. You say that 
the service is medically necessary. The Plan denied your request. The Plan says that the service is not 
medically reasonable and 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 ultrasonic guidance for placement of 
radiation therapy fields. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that using ultrasound on a daily basis is 
not unreasonable to offer but is not necessary. Using daily image-guided radiation therapy (IGRT) for a 
technology for which the need has not been established is not necessary. This would not be furnished in 
accordance with accepted standards of medical practice. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance for placement of radiation therapy fields have not been met. 
Therefore, we decided that the Plan does not have to pre-approve ultrasonic guidance for placement of 
radiation therapy fields.
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 has a complex medical 
history and plan that requires the intervention of several hospital specialists. The Plan denied your request. The 
Plan says  the enrollee does not meet the Medicare criteria for 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 the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. 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 requested 
service cannot be recommended as 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on November 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that a Plan representative told the provider this was 
a covered benefit. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation (D7953) provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on January 04, 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 04, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 14, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. 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 laboratory services 
provided on December 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 9, 2023, billed 
with procedure codes 74230, 74240, 72040-26, 71045-26 and 71045-TC. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. As such, this is a non-covered service. Therefore, 
we decided that the Plan does not have to pay for radiological services provided on January 9, 2023, billed with 
procedure codes 74230, 74240, 72040-26, 71045-26 and 71045-TC.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on December 01, 2022. 
 
You asked the Plan to pay for the office visit (99204). You say that the service was medically necessary. 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 office visit (99204) 
provided on December 01, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sacroiliac joint fusion. 
 
You asked the Plan to pre-approve the sacroiliac joint fusion. You say that  the enrollee has pain with 
ambulation, pain at night, and the feeling of instability when they walk.  The Plan denied your request. The 
Plan says the sacroiliac joint fusion 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 the sacroiliac joint fusion. Our reviewer 
says that the sacroiliac joint fusion is not medically necessary. Our physician reviewer found that the enrollee 
was being treated for sacroiliac joint dysfunction of both sides. However, there is no evidence regarding 
imaging or radiographic evidence supporting a sacroiliitis pathology. There is also no clear history of sacroiliac 
joint pain onset or failure of reasonable and comprehensive conservative treatment directed to the sacroiliac 
joint. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery and multiple other plausible pain generators including at the lumbosacral spine. Additionally, there is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 sacroiliac joint fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the sacroiliac joint fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 27, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the denied 
payment. 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 office visit provided 
on January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on February 13, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. The Plan denied your request. 
The Plan says this is not payable for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on February 13, 2023.