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

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria for 
SNF coverage.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee requires the level of observation and treatment provided in terms of 
physician oversight and skilled nursing care. The enrollee underwent surgery for a femur fracture and is noted 
to have had post-operative hematochezia that required monitoring and the need for possible endoscopy. All 
anti-coagulation was stopped. Physical therapy and occupational therapy documentation indicated that the 
enrollee is now participating in therapy. Currently, the enrollee requires assistance for transfers and maximum 
assistance for toileting. The enrollee has had a significant decline in their mobility and ability to perform daily 
activities and would benefit from physical and occupational therapies in the SNF setting. Therefore, SNF care 
is 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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 Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on January 2, 2023, through 
February 20, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this provider is not enrolled in 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 psychotherapy provided on January 
2, 2023, through February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87086 billed for date of service February 16, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the test is a Medicare covered service. The Plan 
denied your request. The Plan says the billed diagnosis is not covered.  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 CPT code 87086 was billed with diagnosis code C67.8. This diagnosis code is not among those 
that support medical necessity. 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 
87086 billed for date of service February 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of anterior segment aqueous drainage device 
into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or 
more (0671T). 
 
You asked the Plan to pre-approve insertion of anterior segment aqueous drainage device into the trabecular 
meshwork, without external reservoir, and without concomitant cataract removal, one or more. You say that 
this is medically necessary. The Plan denied your request. The Plan says the records do not show that the 
enrollee has mild to moderate glaucoma. Records do not show that the procedure is being performed at the time 
of cataract surgery. 
 
The Plan follows Medicare rules. Medicare rules say that one iStent, iStent inject, or Hydrus device per eye 
will be considered medically reasonable and necessary for the treatment of adults with mild or moderate open-
angle glaucoma and a cataract when the individual is currently being treated with an ocular hypotensive 
medication and the procedure is being performed in conjunction with cataract surgery. 
 
   
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 insertion of anterior segment aqueous 
drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract 
removal, one or more. Our reviewer says that the enrollee does not meet coverage criteria. Our physician 
reviewer found the enrollee has severe stage (not mild or moderate) glaucoma.  Additionally, the enrollee has 
already had prior cataract surgery and the procedure is being requested to be performed as a standalone 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of anterior segment aqueous drainage device into the trabecular 
meshwork, without external reservoir, and without concomitant cataract removal, one or more have not been 
met. Therefore, we decided that the Plan does not have to pre-approve insertion of anterior segment aqueous 
drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract 
removal, one or more (0671T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of congenital 
interarterial communication and echocardiography (PFO closure procedure). 
 
You asked the Plan to pre-approve PFO closure. You say that neurology and cardiology both recommend this 
procedure. The Plan denied your request. The Plan says this 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 PFO closure. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found guidelines point to a recommended age limit of 60 years for this procedure. There is 
insufficient documentation to support this procedure in the enrollee's clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PFO closure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transcatheter closure of congenital interarterial communication and 
echocardiography (PFO closure procedure).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) related services provided 
on August 1, 2022, to August 31, 2022. 
 
You asked the Plan to pay for the ESRD-related services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says ESRD-related services must be billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules state that ESRD related services must be billed correctly. 
The claim should be billed with code G0491 which is a dialysis procedure at a Medicare certified ESRD 
facility for Acute Kidney Injury without ESRD. Therefore, we decided that the Plan does not have to pay for 
the end-stage renal disease (ESRD) related services provided on August 1, 2022, to August 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 30, 2023, billed 
with procedure codes 99244, 74230, 72040, 70100, 70310, and 74240. 
 
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 30, 2023, billed 
with procedure codes 99244, 74230, 72040, 70100, 70310, and 74240.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
March 7, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that medical records were provided. 
The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service March 7, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a SPECT scan (78830). 
 
You asked the Plan to pre-approve a SPECT scan. You say that this service is not medically necessary. The 
Plan denied your request. The Plan says that you are requesting reconsideration of the denied authorization. 
 
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 pre-approve a SPECT scan. Our reviewer says that 
the requested item/service is considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has a history of a tremor. She is noted to have some signs of Parkinsonism on 
exam as well. However, she does not necessarily have any exclusionary criteria for Parkinsons disease (PD). 
In such a setting it would be consistent with the generally accepted standards of practice to have the enrollee 
undergo the requested imaging to rule in/out a diagnosis of PD. 
 
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 SPECT scan have been met. Therefore, we decided that the Plan has to pre-
approve a SPECT scan (78830).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on 
January 6, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676) provided on January 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment with Bupivacaine provided on April 13, 2023. 
 
You asked the Plan to pay for Bupivacaine. 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. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (20610) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for treatment with Bupivacaine provided on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nephrology services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve nephrology care. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and the enrollee can 
be treated within the Plan 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
nephrology services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88361 billed for date of service April 3, 
2023.   
You asked the Plan to pay for procedure code 88361. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88361 is 6. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88361 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88361 billed for date of service April 3, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets Medicare criteria for admission to 
an IRF and will benefit from IRF care that cannot be accomplished at a lower level of care. The Plan denied 
your request. The Plan says that the enrollee does not meet Medicare guidelines for services in 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that, overall, the medical record significantly complies with the various documentation requirements for 
IRF admission. This enrollees condition is in fact complex and fragile, and there is every reason to expect that 
they will participate in and benefit from services to include at a minimum physical therapy, occupational 
therapy, physician management of pain, and essential laboratory monitoring, as well as case manager 
coordination of any additional services that might be needed at home. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
an IRF admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve destruction procedure provided on February 13, 
2023. 
 
You asked the Plan to pay for the nerve destruction procedure. 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 nerve destruction 
procedure provided on February 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services (99309) provided on 
February 2, 2023. 
 
You asked the Plan to pay for SNF care. You say that these services were necessary and were reported 
correctly. The Plan denied your request. The Plan says that the record for this service shows that this care was 
performed and documented by a nurse practitioner. However, the visit was billed by a physician who did not personally render any service or provide any documentation. There is no documentation of direct supervision 
by the physician as required to bill incident-to physician services.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that this service not supported in the medical record. Specifically, there is no evidence that the billing 
physician was involved in the services provided. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled 
nursing facility (SNF) services (99309) provided on February 2, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service September 
13, 2022. 
 You asked the Plan to pay for procedure code 76775. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76775 is bundled into payment for code 76706. 
 
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, we have confirmed that code 76775 
is a column II code to column I code 76706. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 76775 billed for date of service September 13, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 26, 2022, to 
November 7, 2022. 
 
You asked the Plan to pay for the home health services. You say that it was not t until you had several patients 
claims be denied that you were told an NOA was required. The Plan denied your request. The Plan says the 
NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 26, 2022. The NOA was not received by the Plan until January 11, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from October 26, 2022, to November 7, 2022.