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

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the physician service. You say that you are not able to get your medical 
supplies since you do not have a provider. You say that you moved in August and cannot get in to see any of 
the Plan providers that you called for 6 months to a year. You also say that you cannot wait this long to get 
your supplies. The Plan denied your request. The Plan says there are network providers available to provide 
this service within a reasonable amount of time. 
 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 confirmed there are 
network providers available within a reasonable time 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 an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 22, 2021, 
to April 1, 2022. 
 
You asked the Plan to pay for the inpatient hospital services provided. You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says that the requested documentation has 
not been provided for review. 
 
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 the inpatient hospital services provided 
have been met. Specifically, the complete medical records and itemized billing summary requested have not 
been provided for review. Therefore, we decided that the Plan does not have to pay for inpatient hospital 
services provided on December 22, 2021, to April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on May 03, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for lab testing. You say that please see the attached documents appealing the denial 
for medical necessity. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 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 lab testing provided on May 03, 2023, by an out-
of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that due to the enrollee's condition, the enrollee would 
benefit from inpatient rehabilitation facility (IRF) services. The Plan denied your request. The Plan says the 
inpatient rehabilitation facility (IRF) services you are requesting do 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 enrollee's 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 lumbar spine surgery. Medical problems are stable. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85007 billed for date of service May 16, 
2023.  
 
You asked the Plan to pay for procedure code 85007. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 85007 is bundled into payment for code 85025. 
 
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 85007 
is a column II code to column I code 85025 with a modifier indicator of 0. The column II code is therefore not payable. 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 85007 billed for date of service May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive lumber or lower back 
decompression. 
 
You asked the Plan to pre-approve minimally invasive lumber or lower back decompression. You say that it is 
medically necessary. The Plan denied your request. The Plan says it 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 minimally invasive lumber or lower 
back decompression. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found percutaneous lumbar decompression 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 minimally invasive lumber or lower back decompression have not been met. 
Therefore, we decided that the Plan does not have to pre-approve minimally invasive lumber or lower back 
decompression.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's medical management is too 
complex for a lower level of care. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 (x5) and 87798 billed for date of 
service March 20, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these codes are not 
supported in the medical record. 
 
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 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 procedure codes 83520 and 87798. Our reviewer says that 
these codes are not supported. Our reviewer found there are no lab orders or documentation to support 5 units 
of code 83520 and one unit of code 87798. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 83520 and 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 83520 (x5) and 87798 billed for date of service March 
20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinical crown lengthening (D4249) provided on April 10, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay more for this. 
The Plan denied your request. The Plan says your annual dental allowance amount has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 10, 2023. Any 
charges over your annual dental allowance amount is not covered. Therefore, we decided that the Plan does not 
have to pay for clinical crown lengthening (D4249) provided on April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 30, 2021, billed 
with codes 88377, 88377- 59, 88377-26, 88377-91, 88350, and 88346-26-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting full payment for the 
Biocept testing. The Plan denied your request. The Plan says panel testing should be billed using one CPT code 
on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 30, 2021, billed with codes 88377, 88377- 59, 88377-26, 88377-91, 88350, and 88346-26-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy. 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that it is medically necessary. The Plan 
denied your request. The Plan says there are insufficient long-term efficacy and safety data to support the 
routine use of electronic surface brachytherapy. 
 
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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case is unfavorable due to lack of demonstration of need for sterotactic 
radiotherapy (SRT) vs. traditional external beam 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 electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for 4 units of code Q0092, defined as set-up of portable x-ray equipment, 
performed on date of service May 15, 2023. 
 
You asked the Plan to pay for 4 units of code Q0092. You say that 4 units of Q0092 should be paid as billed 
because all 4 units are supported in the documentation. The Plan denied your request. The Plan says that 4 units 
of Q0092 are denied because they are not supported in the record. Documentation contains only 3 radiology 
reports. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. The rules also say that carriers must pay a set-up component for each 
radiologic procedure (other than retakes of the same procedure) during both single patient and multiple patient 
trips. 
 
We find that 4 units of CPT code Q0092 are supported in the medical record. There is evidence in the 
documentation that 4 separate x-rays took place on this date of service. While the records originally submitted 
in the case file showed only 3 x-rays, the additional information sent directly to us included an x-ray report for 
each of the 4 billed radiology codes. Based on this information, we decided that Medicare rules for coverage of 
4 units of code Q0092 have been met. Therefore, we decided that the Plan has to pay for 4 units of code Q0092, 
defined as set-up of portable x-ray equipment, performed on date of service May 15, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services. The Plan denied 
your request. The Plan says an IRF admission is not reasonable and necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
does not support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  The 
enrollee can receive further services at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
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 a SNF admission is necessary. The Plan denied your 
request. The Plan says the rules for SNF care have not been met. 
 
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 for SNF admission. 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 clinical documentation shows that the enrollees current level of function is 
max assist/dependent after an inpatient rehabilitation course without clear further inpatient therapy goals 
documented. The clinical documentation does not specify any daily skilled nursing needs, thus does not support 
daily skilled services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 semi-electric hospital bed (E0261) and a powered 
pressure-reducing air mattress (E0277) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a hospital bed and a mattress. You say that your health is in danger, and you 
cannot for the equipment, it is medically necessary. The Plan denied your request. The Plan says you must 
receive your care and services from a network provider. 
 
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 
a semi-electric hospital bed (E0261) and a powered pressure-reducing air mattress (E0277) to be provided by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 8, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says these services are not covered by Medicare. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 26, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that 70450 should be paid as billed because the 
enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87491, 87500, 87563, 87640, 87641, 
87653, 87798) provided on May 30, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 the lab services have been met. No lab 
or clinical records were provided to support the codes billed. The plan requested additional information and 
none was provided. Therefore, we decided that the Plan does not have to pay for lab services (87481, 87491, 
87500, 87563, 87640, 87641, 87653, 87798) provided on May 30, 2023.