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

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) services 
(G6001). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says IGRT is experimental/investigational for the enrollee's condition. 
 
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 IGRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that usually IGRT is used when critical structures are abutting or in close proximity to the target that is 
being treated to high doses. This scenario does not apply for the enrollee, for whom the target lesion can be 
seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. Billing for daily IGRT which 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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT) services (G6001).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan, thorax, diagnostic; without contrast material 
(71250) provided on April 19, 2023. 
 
You asked the Plan to pay for the out-of-network CT scan. You say that there is an approved authorization on 
file.  The Plan denied your request. The Plan says their records show an approved authorization 171549803 
exists; however, 71250 does not match what was approved on the authorization. The Plan states the provider is 
not listed on the authorization 
 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 provider that was approved on 
the authorization does not match who the services were provided from. The provider on this claim is not listed 
on the authorization. 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 the CT scan, thorax, diagnostic; without contrast 
material (71250) provided on April 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically 
necessary.  The Plan denied your request. The Plan says the enrollee does not meet the criteria for 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 enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care soon. The enrollee does not require services at the LTACH that are not already available at the current facility. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (37228, 37224, 37220 and 76937) 
provided on January 10, 2023. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the documentation does not support these 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 definition of code 37228 is revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. The definition of 
code 37224 is revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; 
with transluminal angioplasty. The definition of code 37220 is revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty. The definition of code 76937 is ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure). 
 
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 medical services. Our reviewer found the medical records 
do not support  procedures 37228, 37224, 37220 and 76937. The procedure note documented a below the knee 
amputation was done. The medical records cannot verify the procedure codes billed. 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services (37228, 37224, 37220 and 76937) provided on January 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lybalvi. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been using this medication and 
is stable and doing well. 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 Lybalvi.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on April 3, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that this service was necessary and has been covered 
in previous years. The Plan denied your request. The Plan says this service was billed as a non-covered eye 
refraction rather than a routine eye exam. This service is not covered when it is not performed as part of a 
routine eye exam. 
 
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 covers these services only once per calendar year when performed as part of a routine (non-
medical) eye exam. 
 
We looked at the file and the Plan's rules. The eye refraction in this case was performed during the course of a 
medical eye exam and was not billed as a routine vision exam. Based on this information, we decided that the 
Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not 
have to pay for the eye refraction (92015) provided on April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87502, 87581, 87634, 87651, 87798, 
U0003, U0005) billed for date of service December 23, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
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 regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
laboratory services (87502, 87581, 87634, 87651, 87798, U0003, U0005) billed for date of service December 
23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 and 95955 rendered on February 10, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
Healthcare Common Procedure Coding System (G0453): 
 
Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), 
per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary 
procedure) 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 95955, the 
procedure report describes neuromonitoring service provided for interhemispheric craniotomy for distal 
anterior communicating artery (ACA) aneurysm clipping procedure. In this case, there is a more appropriate 
procedure code to report for service documented. 
 
In terms of HCPCS G0453, the provider reported this code with modifier XU - unusual non-overlapping 
service. As CPT 95955, using modifier XU to report G0453 as unusual and non-overlapping would not 
supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code G0453 and 95955 rendered on February 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires SNF care after their hospital 
discharge because they are blind and immobile. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
The plan has indicated coverage for such a device is available upon request. The elements of the coverage 
criteria are not satisfied. 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing of 22 or more drug class(es), including 
metabolite(s) if performed (G0483) provided on January 9, 2023. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The submitted medical records include a physician's order; however, the order submitted does not clearly 
indicate that 22 or more drug classes were ordered on the billed date of service. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing of 22 or more drug class(es), including metabolite(s) if performed 
(G0483) provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device for arterial insufficiency 
(E0675), pump for water circulating pad (E0236) and pad (E0249). 
 You asked the Plan to pay for the pneumatic compression device for arterial insufficiency (E0675), pump for 
water circulating pad and pad . You say that the items should be covered. The Plan denied your request. The 
Plan says these are not covered items. 
 
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 for arterial insufficiency (E0675), pump for water circulating pad 
(E0236) and pad (E0249).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 
18, 2023, to February 28, 2023. You asked the Plan to pay for SNF care. You say that these services were medically necessary. The Plan denied 
your request. The Plan says the enrollee did not need daily skilled nursing or therapies. 
 
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 pay for 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 did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
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 pay for skilled nursing facility (SNF) care provided from February 18, 2023, to February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reconsidered. The Plan 
denied your request. The Plan says you did not timely file your claim. The Plan follows Medicare rules. The 
rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar 
year after the date of service. The record shows that a claim for the lab services was not filed until March 22, 
2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for lab services provided on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder oncology genetic testing (0012M) provided on 
March 2, 2023. 
 
You asked the Plan to pay for oncology genetic testing. You say that the service at issue was a medical 
necessity for the enrollee. 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 CxBladder is a non-covered service. Based on 
this information, we decided that Medicare rules for coverage of oncology genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for CxBladder oncology genetic testing (0012M) 
provided on March 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient psychiatric admission provided February 28, 
2023, to March 13, 2023. 
 
You asked the Plan to pay for an inpatient psychiatric admission. You say that this admission and stay were 
medically necessary. The Plan denied your request. The Plan says the enrollee had no psychotic symptoms, no 
aggression, has a bright affect, and makes good eye contact during interview. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 an inpatient psychiatric admission. Our 
reviewer says that this admission was not medically necessary. Our physician reviewer found the admission of 
this enrollee does not meet the criteria for July 4, 2023 forward as this enrollee was not shown to be a danger to 
herself or others, delusions, auditory or visual hallucinations noted. She was cooperative/compliant with 
treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pay for an inpatient psychiatric admission provided February 28, 2023, to March 
13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20610 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 20610. You say that you have billed the service 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 20610 is: Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. 
 
We find that CPT code 20610 is not supported. Specifically, the service at issue has been billed with two 
unilateral diagnosis codes. There is a more appropriate and specific bilateral code available to use. Based on 
this information, we decided that Medicare rules for coverage of procedure code 20610 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 20610 billed for date of service 
August 29, 2022.