Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy services. 
 
You asked the Plan to pre-approve physical therapy. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had a significant response to therapy but remains with 
impairment despite continued therapy. The enrollee requires a continued exercise program which may be done 
at home. The enrollee has an effective program which can maintain or improve the enrollees condition and 
does not require continued input from a skilled therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided the Plan does not 
have to pre-approve continued physical therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on December 16, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components.  
 
We looked at the file and Medicare rules. The testing in this case was billed with multiple codes and units of 
service, not one unit of one code as required by A58726. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the testing provided on December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the human floor lift (E1399) and shipping (99199).  
 
You asked the Plan to pay for the human floor lift and shipping. You say that the services should be covered. 
The Plan denied your request. The Plan says this was 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 human floor lift (E1399) and 
shipping (99199).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005, 74176, and 96368 billed for date of 
service December 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are covered on the fee schedule. The 
Plan denied your request. The Plan says the services are not payable. 
 
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 93005, 74176, and 96368 are not separately payable. 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 codes 93005, 74176, and 96368 billed for date of service December 
12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone 50MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone 50MG tablet.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman G5 MIS Fusion Plate fixation device. 
 
You asked the Plan to pre-approve a Minuteman G5 MIS Fusion Plate fixation device. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 Minuteman G5 MIS Fusion Plate 
fixation device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the minuteman plate is experimental. More research is 
needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Minuteman G5 MIS Fusion Plate fixation device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Minuteman G5 MIS Fusion Plate fixation 
device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on February 22, 2021, billed with 
codes 95955-26-XU, 95861-26-59, 95937-26 and 95927-26-59. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 definitions of codes 95955-26-XU, 95861-26-59, 95937-26 and 95927-26-
59 are; Electroencephalogram (EEG) during nonintracranial surgery, Needle electromyography; 2 extremities 
with or without related paraspinal areas, Neuromuscular junction testing (repetitive stimulation, paired stimuli), 
each nerve, any 1 method, and Short-latency somatosensory evoked potential study, stimulation of any/all 
peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head.  
We asked our coder 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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found the billed procedure codes cannot be 
verified in the documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on February 22, 2021, billed with codes 95955-26-XU, 
95861-26-59, 95937-26 and 95927-26-59.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit (J0885). 
 
You asked the Plan to pre-approve Procrit. The Plan denied your request. The Plan says the requested drug is 
not being prescribed in a medically accepted reasonable and necessary manner. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage.  Therefore, we decided that 
the Plan does not have to pre-approve Procrit (J0885).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with computed 
tomography (CT) (78431). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that taking it easy is not a feasible option. You also 
say that you need help getting this needed medical intervention sooner rather than later. The Plan denied your 
request. The Plan says Medicare rules have not been met and therefore, the request cannot be approved. 
 
The Plan follows Medicare rules. Medicare rules say that the PET scan, whether at rest alone or rest with stress, 
is used following a SPECT that was found to be inconclusive. 
 
 
 
 
 
 
 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 PET/CT scan. Our reviewer says that 
a PET/CT scan is not medically reasonable and necessary. Our physician reviewer found previously mildly 
abnormal stress echo-cardiogram test on February 24, 2023, with no new symptoms or clinical findings is 
adequate for decision making regarding the medical management versus invasive studies, and a repeat stress 
test with PET/CT does not benefit you. Our reviewer also found that in fact, it can harm due to unnecessary 
exposure to radiation. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with computed tomography (CT) (78431).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 02, 
2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are disputing the share cost. 
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 $160 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $160 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 an ultrasound provided on February 02, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial 
of a SNF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
guidelines for services in a SNF.  
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. However, the enrollee is not medically stable for 
transfer from the acute hospital setting. The enrollee does have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. However, the enrollee is not 
medically stable for transfer from the acute hospital setting. The enrollee does not require daily skilled services 
on an inpatient basis only in a skilled nursing facility (SNF) setting. Further stabilization in the acute hospital 
setting is indicated based on the available 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A0398 and A0422 billed for date of service 
December 9, 2022. 
 
You asked the Plan to pay for procedure codes A0398 and A0422. The Plan denied your request. The Plan says 
procedure codes A0398 and A0422 are not payable. 
 
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 A0398 and A0422 have a status indicator of X on the Physician Fee Schedule. This means that procedure codes A0398 and A0422 are not payable. Based on this information, we decided that 
Medicare rules for coverage of procedure codes A0398 and A0422 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes A0398 and A0422 billed for date of service December 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion of Solaris (J1300) provided on November 29, 
2022. 
 
You asked the Plan to pay for the infusion of Solaris (J1300). 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 infusion of Solaris 
(J1300) provided on November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on June 16, 2022, billed with codes 
36248, 77001, 75625-26-59, 36247-59, 75710-26-59, and 75736-26-59. 
 You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says codes 36248, 77001, and 75625-26-59 are not 
supported by the documentation. The Plan also says codes 36247-59, 75710-26-59, and 75736-26-59 are 
inclusive to code 37228. 
 
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 codes 36247-59, 75710-26-59, and 75736-26-59 are column II codes to 
column I code 37228; however, 36247-59, 75710-26-59, and 75736-26-59 were billed with a modifier.  
 
We asked our coder 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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that though codes 36247-59, 75710-26-
59, and 75736-26-59 are included in the documentation, they are considered inclusive to the primary 
procedure. Codes 36248 and 75625-26-59 are not found to be reported in the documentation, and code 77001 is 
an add on code that was listed without an appropriate primary procedure code, therefore these codes cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on June 16, 2022, billed with codes 36248, 77001, 
75625-26-59, 36247-59, 75710-26-59, and 75736-26-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a peripheral nerve block (64479) provided on October 26, 
2022. 
 
You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the peripheral nerve block does not meet the Medicare LCD coverage criteria. 
 
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 service. Our physician reviewer found 
the LCD for peripheral nerve block is not relevant to this case. There was no indication for a transforminal 
epidural steroid injection (ESI) at this level. The procedure was not medically reasonable and 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for a peripheral nerve block (64479) provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the midwifery care. 
 
You asked the Plan to pre-approve the midwifery care. You say that the service should be covered. The Plan 
denied your request. The Plan says a Licensed Midwife, LM is not eligible to enroll in Medicare and therefore, 
not payable under the enrollees coverage. 
 
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 pre-approve the midwifery care.
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. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and the enrollee's needs can be met in another setting. 
 
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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of the Barostim Neo system (0266T and 
C1825). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the placement of the Barostim Neo system is not medically necessary for 
this enrollee and is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the placement of the Barostim Neo system (0266T and C1825).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480) provided on October 28, 2021. 
 You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported in the 
medical records. The Plan denied your request. The Plan says the provided records do not include a laboratory 
order or test requisition form. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, the records provided do not include a signed physician order or any progress notes from the 
referring physician. Without this information, we cannot verify that these services were medically necessary 
and were requested by the enrollees treating physician. Therefore, we decided that the Plan does not have to 
pay for drug testing services (G0480) provided on October 28, 2021.