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

 
We decided that the Plan has to pre-approve a repeat computed tomography (CT) scan, thorax, diagnostic; 
without contrast material.  
 
You asked the Plan to pre-approve a repeat CT scan of the thorax, diagnostic; without contrast material. You 
say that a repeat CT scan of the thorax is medically necessary. The Plan denied your request. The Plan says that 
your doctor did not tell us what other tests you have had for this problem. Your doctor did not tell us what has 
been done to help you. Your doctor did not tell us why other tests cannot be done first. We also need to know 
how this test will change how your doctor treats you. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat CT scan of the thorax, 
diagnostic; without contrast material. Our reviewer says that the repeat CT scan of the thorax is considered 
medically necessary in this case. Our physician reviewer found a follow-up CT scan of the chest is considered 
reasonable and medically necessary. You were hospitalized in December 2022 for dyspnea and hypoxemia. A 
CT scan reportedly showed mediastinal lymph node enlargement, and sarcoidosis was in the differential 
diagnosis. You had diastolic heart failure at that time. You were seen in pulmonary follow-up on  
February 15, 2023, and the note indicates "hilar and mediastinal nodes prominent but nonspecific".  The 
follow-up CT scan was planned. This test is necessary to reassess the mediastinal adenopathy. If it is improved 
or unchanged, no further diagnostic studies would be indicated. 
 
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 repeat CT scan of the thorax, diagnostic; without contrast material have been 
met. Therefore, we decided that the Plan has to pre-approve a repeat CT scan, thorax, diagnostic; without 
contrast material.   
 
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 procedure code 99217 billed for date of service December 
16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the correct codes were assigned. The Plan 
denied your request. The Plan says a qualifying initial or subsequent code was not found. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 We looked at the file and the rules. The claim information shows that the enrollee was receiving inpatient care 
at the time the evaluation and management (E&M) services were provided. There is a more applicable code to 
describe inpatient E&M services. 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 99217 billed for date of service December 16, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis. She has 
not tried and failed the Plan's required drug, zoledronic acid. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the surgery services provided from May 24, 2022, to May 25, 2022. 
 
You asked the Plan to pay for the billed services. You say that no authorization was required. The Plan denied 
your request. The Plan says that the service is not covered when performed on the same day as an inpatient 
procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. In this case, a claim was not provided. The Plan denied services as not 
covered when billed with an inpatient procedure. The Plan did not provide documentation of the procedure 
codes that substantiated their denial. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for the surgery services provided from May 24, 2022, to May 25, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service December 19, 2022, billed with code 99153. 
 You asked the Plan to pay for procedure code 99153. You say that the sedation should also be paid as it was 
medically necessary. The Plan denied your request. The Plan says code 99153 is not payable in the facility 
setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service December 19, 2022, 
billed with code 99153.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on February 15, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the services are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the SNF must furnish the services either directly 
or under an arrangement with an outside supplier or provider of services in which the SNF (rather than the 
supplier or provider of services) bills Medicare. Medicare does not pay amounts that are due a provider to any 
other person under assignment, or power of attorney, or any other direct payment arrangement.   
We looked at the file and Medicare rules. In this case, the requested supplies are included in the payment to the 
SNF and are not separately payable. Based on this information, we decided that Medicare rules for coverage of 
the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the supplies 
provided on February 15, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care provided for dates of service January 5, 2022, to 
January 28, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the NOA 
was submitted beyond the required time limit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. In this case, a valid NOA was submitted. The explanation of benefits 
associated with the NOA claim has a date of January 14, 2022. Although the exact date of the NOA submission 
is not noted on the explanation of benefits, the date shows that more than 30 days had not passed between the 
timely filing date and the NOA receipt. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for the home health care provided for dates of service January 5, 2022, to January 28, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 28, 2022, to 
March 9, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted a corrected bill with 
an updated admit date.  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 January 19, 2022. The NOA was not received by the Plan until March 10, 
2022. 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 home health services provided 
from February 28, 2022, to March 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says you 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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for altered mental status and congestive heart failure. Medical problems are stable. There 
are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services with an out-of-network (OON) endovascular 
neurosurgical radiologist 
 
You asked the Plan to pre-approve services with an OON endovascular neurosurgical radiologist. You say that 
the requested OON provider performs minimally invasive procedures that cannot be done by a simple 
neurologist, neuroradiologist, neurosurgeon or radiologist. You say that the requested OON provider had 
training in a sub-specialty and had 2-3 years of training in this highly sub-specialized field. You say that the 
enrollee has a 3-millimeter aneurysm and needs to be treated by an expert. You say that there are no in-network 
providers that have extensive experience dealing with the complicated cerebral aneurysms.  The Plan denied 
your request. The Plan says they have in-network provider who can supply the care needed.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 services with an OON endovascular 
neurosurgical radiologist. Our reviewer says that the criteria for coverage of OON care have not been met.  Our 
physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to 
meet the enrollee's medical needs through referral to network providers. Our physician reviewer found that the 
network provider the Plan has referred you to has extensive training and experience with aneurysm treatment. 
There is nothing unique about the enrollee's condition that would make it medically necessary to see the 
requested OON provider. The case file shows that the network provider has the training and experience to meet 
the Standards of Care required for treatment of the enrollee's condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of services with an OON endovascular neurosurgical radiologist have not been 
met. Therefore, we decided that the Plan does not have to pre-approve services with an out-of-network (OON) 
endovascular neurosurgical radiologist
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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does meet the requirements for approval. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. All medically necessary care is being 
provided in the current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on July 14, 2022, billed with 
code 30465. 
 
You asked the Plan to pay for the services as billed. You say that this was the correct code, and it should be 
paid.  The Plan denied your request. The Plan says the records do not support the use of this code. 
 
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 30465 is repair of nasal vestibular stenosis (eg, spreader 
grafting, lateral nasal wall reconstruction). 
 
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 as billed. Our reviewer says that the code at issue is not supported in the records.  Our reviewer found the procedure report does not include sufficient 
documentation to confirm repair of nasal vestibular stenosis. The coding policy manual states that for the 
services described by this code, the physician makes an incision in the upper lateral cartilage, in another 
approach a "V" shaped cut may be made. In either case, the incision is followed by an osteotomy of the medial 
aspect of the nasal bones. A spreader graft is placed to widen the nasal vestibule. The incision is closed or 
closed in a V-Y manner (lengthens the columella) with suture. This description is not evidence in the operative 
note.  
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services provided on July 14, 2022, billed with code 30465.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an attended polysomnography (PSG) (95810). 
 
You asked the Plan to pre-approve an attended PSG. You say that an in-lab study is medically necessary to 
address excessive daytime sleepiness and snoring. The Plan denied your request. The Plan says that this request 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that all reasonable and necessary diagnostic tests 
given for specifically listed medical conditions, including sleep apnea, are covered when the criteria listed in 
the Medicare rules section of this letter are met. 
 
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 an attended PSG. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case support the need for a sleep study due to symptoms of 
obstructive sleep apnea. Our reviewer found that the Medicare rules do not say that lack of those comorbidities 
requires a home sleep study. Our physician reviewer also found that based on the provided information and 
these rules, an in-lab sleep study is eligible for coverage by Medicare rules in this case. 
 
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 attended PSG have been met. Therefore, we decided that the Plan has to pre-
approve an attended polysomnography (PSG) (95810).  
 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 procedure code 99153 billed for November 21, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only stand alone codes. 
 
We looked at the file and Medicare rules. Procedure code 99153 has a PC/TC indicator of 3 and no separate PC 
payment. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed for 
November 21, 2022.