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

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
dermatologist.  
 
You asked the Plan to pre-approve the continuation of care with an OON dermatologist. You say that the 
enrollee has been a patient of the requested OON dermatologist since 2017. You say that the enrollee's history 
of cancer, both breast and skin, warrants having someone that she feels comfortable with and who knows her 
history.  The Plan denied your request. The Plan says there are numerous dermatologists in the enrollee's 
network that can see her for yearly dermatology exams and follow-up care.  
 
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 the continuation of care with an OON 
dermatologist. Our reviewer says that the criteria for coverage of OON care have not been met.  Our physician 
reviewer found the record indicates that the enrollee has dysplastic nevi and a history of squamous cell 
carcinoma.  The record provided does not establish that the enrollee requires emergent or urgent care or that 
she is receiving active treatment such that transferring her care and medical management to another provider 
would be medically inappropriate and/or contraindicated at this time. 
 
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 continuation of care with an OON dermatologist have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out-of-network 
(OON) dermatologist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve, each additional vertebral body (64629 x 2). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this has been approved by the Food 
and Drug Administration (FDA) for up to four vertebral bodies in one surgical setting. The Plan denied your 
request. The Plan says there is not enough medical proof that shows the safety or success of this procedure. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not clearly show the cause of the enrollee's 
pain. Therefore, the reviewer found that the requested Intracept procedure is not medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the thermal destruction of intraosseous basivertebral nerve, each additional 
vertebral body (64629 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 for date of service 
April 24, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, and 96521. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed 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. 
 
We find that CPT codes 96365, 96366, and 96521 are not supported in the medical record. Specifically, the 
documentation indicates that Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or 
continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea 
nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed. 
This means there is a more appropriate code to be billed for the services rendered. Therefore, codes 96365 and 
96366 are not supported. The medical records submitted include an order to perform refilling and maintenance of portable pump. However, the records indicate that Outpatient Intravenous Insulin Treatment (OIVIT) was 
performed and doesnt include a procedure report for pump maintenance refill. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 96365, 96366, and 96521 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 for date 
of service April 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve Botox. 
 
You asked the Plan pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 pre-approve the medication. Our reviewer says that the 
request is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of perineal pain. The FDA has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. 
 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 medication have not been met. Therefore, we decided that the Plan does not 
have pre-approve Botox.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service October 12, 
2022, to November 9, 2022. You asked the Plan to pay for the billed services. You say that an NOA has been provided. The Plan denied 
your request. The Plan says the NOA was not received timely. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 12, 2022. The NOA was not received by the Plan until March 15, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service October 12, 2022, to November 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a TORIC correcting astigmatism cataract surgery. 
 
You asked the Plan to pre-approve IOL insertion for cataract surgery. You say that you needed these services. 
The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
an IOL insertion for cataract surgery is not a covered benefit. Vision correcting and astigmatism (TORIC) 
correcting IOL insertion in lieu of conventional IOL insertion for cataract surgery is excluded from coverage under original Medicare. Therefore, we decided that the Plan does not have to pre-approve a TORIC correcting 
astigmatism cataract surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
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 services are not medically necessary.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic respiratory 
failure from chronic obstructive pulmonary disease (COPD). She was successfully treated with bi-level positive 
airway pressure (BiPAP) therapy. The records do not contain sufficient detailed information in the medical 
record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
The criteria for coverage are not met and the requested ventilator 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 a portable ventilator.
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 meets all of the criteria for an IRF level 
of care. The Plan denied your request. The Plan says the 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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
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 pay for practitioner services provided on November 25, 2022, billed 
with procedure code 00530-QX-QS-78. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the procedure code is inconsistent with the 
modifier used. 
 
The Plan must follow Medicare rules. Medicare rules say that payment can be made under the fee schedule for 
anesthesia services associated with multiple surgical procedures when reported with an appropriate modifier. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the practitioner services provided have not been met. This claim has not been reported with an 
appropriate modifier for the service provided. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on November 25, 2022, billed with procedure code 00530-QX-QS-78.
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. You say that the medical records support the medical necessity for 
IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines and the information 
we have about the enrollee's condition they do not meet all the requirements for IRF admission. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for atrial fibrillation, congestive heart failure and cellulitis. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. While the medical records support 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 the 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 the respiratory panel testing billed for date of service January 
17, 2023. 
 
You asked the Plan to pay for the billed services. You say that you were not aware the testing was ordered. The 
Plan denied your request. The Plan says the test does not meet the coverage criteria. 
 
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 looked at the file and the rules. We find that the panel testing was not billed with a single code as required. 
The records do not show that target panel testing was not appropriate. 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 the respiratory panel testing billed for date of service January 17, 2023.  
 
Please note, the explanation of benefits show that you do not owe any more for the services at issue. If the 
provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882-26 billed for date of service February 
21, 2023. You asked the Plan to pay for procedure code 76882. You say that the code was not bundled with any other 
procedure performed. The Plan denied your request. The Plan says payment for code 76882 is bundled into 
payment for code 93970. 
 
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 76882-26 is a column II code to column I code 93970. The code at 
issue 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 76882-26 billed for date of service February 21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services received on February 21, 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 this was billed with an incorrect type of bill. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report home health services 
correctly, with the correct type of bill. 
 
We find that the home health services are not supported in the medical record. Specifically, based on the rules, 
a type of bill of 0323 is not valid in this instance. The rules say that the fourth digit must be 9. 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 home health services received on February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87481, 87641, 87653, 87798) provided 
on February 17, 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 billed codes are not separately 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 codes 87150, 87481, 87641, 87653, & 87798 are not supported in the medical record. 
Specifically, code 87150 is included in code 87500 that was also billed. Codes 87481, 87641, 87653, & 87798 
are included in code 87150. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87150, 
87481, 87641, 87653, 87798) provided on February 17, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee requires more visits as they 
are still having difficulty navigating stairs. The Plan denied your request. The Plan says the requested services 
are not medically reasonable and necessary. 
 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 the therapy services. 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 member has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
members medical condition and therefore are not 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450 billed for date of service March 20, 
2023. 
 You asked the Plan to pay for procedure code 64450. The Plan denied your request. The Plan says payment for 
code 64450 is bundled into payment for code 01402. 
 
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 64450 
is a column II code to column I code 01402. 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 64450 billed for date of 
service March 20, 2023.