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

 
We decided that the Plan does not have to pre-approve a CT colonography. 
 
You asked the Plan to pre-approve a CT colonography. You say that a CT colonography is medically 
necessary. The Plan denied your request. The Plan says a CT colonography is not medically necessary. 
 
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 CT colonography. Our reviewer says 
that the requested CT colonography is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient with a history of three polyps found on colonoscopy three years ago, 
recent positive Cologuard test, gastrointestinal (GI) bleed, melena. A CT colonography was requested to screen 
for bowel cancer as the prescriber felt that the patient was not a good candidate for upper or lower endoscopy 
due to age. A bleeding scan was suggested by the Plan instead. However, CT colonography is not covered as a 
screening tool and guidelines recommend colonoscopy as next step after positive Cologuard. Therefore, this 
request for CT will be considered 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 a CT colonography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a CT colonography.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of anterior segment aqueous drainage device 
(66183) provided on August 07, 2023. 
 
You asked the Plan to pay for the insertion of anterior segment aqueous drainage device (66183). You say that 
the service was medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the insertion of anterior 
segment aqueous drainage device (66183) provided on August 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient cataract surgery provided on 
August 7, 2023. 

You asked the Plan to waive the copayment for outpatient cataract surgery. You say that the services should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $320 
copayment for Medicare-covered services provided in an ambulatory surgery center.  
 
You have been asked to pay a $320 copayment for outpatient cataract surgery. This item/service falls within 
the Medicare-covered services provided in an ambulatory surgery center benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for outpatient cataract surgery provided on August 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete bilateral noninvasive physiologic studies of 
upper or lower extremity arteries (93923), autonomic testing (95923), and parasympathetic testing (95999) 
provided on August 31, 2023. 
 
You asked the Plan to pay for the peripheral artery study and neurological studies. You say that the medical 
records support the medical necessity of the billed services. The Plan denied your request. The Plan says the 
records do not support that the enrollee has claudication, rest pain, tissue loss, evidence of thromboembolic 
events, aneurysmal events, or trauma. The Plan also says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that peripheral artery studies may be considered medically 
necessary if claudication of such severity interferes significantly with the patients occupation or lifestyle, or 
claudication with inability to stress the patient. Additionally, autonomic function testing is covered as 
reasonable and necessary when used as a diagnostic tool to evaluate symptoms indicative of vasomotor 
instability and the ANS testing is directed at establishing a more accurate or definitive diagnosis or contributing 
to clinically useful and relevant medical decision making for autonomic neuropathy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the peripheral artery study and neurological 
studies. Our reviewer says that the peripheral artery study and neurological studies are not medically necessary. 
Our physician reviewer found the provided records do not satisfactorily describe symptoms consistent with 
claudication, as required for peripheral artery studies. There is no evidence of rest pain or tissue loss. There is 
no evidence of thromboembolic events, aneurysmal events, or lower extremity trauma. Additionally, the 
provided records document diagnoses of bilateral carotid bruits, dizziness and giddiness, idiopathic peripheral autonomic neuropathy among other conditions but records provide no details to show signs or symptoms 
suggesting a progressive autonomic neuropathy, syncope, distressing symptoms suspicious for distal small 
fiber neuropathy, postural tachycardia syndrome or any autonomic deficits. Therefore, the reviewer found that 
the peripheral artery study and neurological studies are 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 peripheral artery study and neurological studies have not been met. 
Therefore, we decided that the Plan does not have to pay for the complete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries (93923), autonomic testing (95923), and parasympathetic testing 
(95999) provided on August 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill
(SSBCI).

You asked the Plan to pre-approve SSBCI benefits. You say that you feel services should be covered. The Plan
denied your request. The Plan says the criteria for eligibility have not been met. Maximus overturned the Plan's
denial for lack of information. The Plan requested a reopening and stated that you do not meet criteria for these
benefits and provided medical records for review.

The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a
documented chronic condition that is life threatening or significantly limits the health or function of the
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an
eligible condition that meets all the required criteria. Your physician confirmed that you do not need intensive
care management and are not at high risk for hospitalization. Therefore, we decided that the Plan does not have
to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that skilled nursing facility services are necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not have a need for daily skilled 
nursing care and does not need daily skilled therapy. The Plan says the enrollee requires services called 
custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 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 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative monitoring provided on May 4, 2023. 
 
You asked the Plan to pay for intraoperative monitoring. You say that this is necessary to protect the enrollee 
against facial nerve injury. The Plan denied your request. The Plan says this is not medically necessary and not 
payable when used during cochlear implant placement. 
 
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 intraoperative monitoring. Our reviewer says that the service is not medically necessary. Our physician reviewer found the LCD does not support 
intraoperative neuromonitoring for cochlear nerve implantation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraoperative monitoring have not been met. Therefore, we decided that the 
Plan does not have to pay for intraoperative monitoring provided on May 4, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J9357-JG billed for date of service September 7, 2023. 
 
You asked the Plan to pay for the billed code. You say that the billed code was previously paid. The Plan 
denied your request. The Plan says that the code is 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 code.  
 
We looked at the file and the rules. We find that code J9357 is separately payable when billed with the JG 
modifier. Based on this information, we decided that Medicare rules for coverage of the billed code have been 
met. Therefore, we decided that the Plan has to pay for procedure code J9357-JG billed for date of service 
September 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot (L4361) provided on July 10, 2023. 
 
You asked the Plan to pay for the walking boot (L4361). You say that the item was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the walking boot 
(L4361) provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on July 13, 2023. 
 
You asked the Plan to pay for the office visit (99214). You say that the service was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99214) 
provided on July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87389) provided on August 28, 
2023. 
 
You asked the Plan to pay for the laboratory services. 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 covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (87389) provided on August 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
August 06, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the cost share is 
wrong. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room services. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
services provided on August 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a unilateral open endovascular revascularization of 
femoral artery with transluminal stent placement and atherectomy. 
 
You asked the Plan to pre-approve a unilateral open endovascular revascularization of femoral artery with 
transluminal stent placement and atherectomy. You say that the enrollee has difficulty healing wound on the 
right third toe and a recent wound to the right lateral malleolus. The Plan denied your request. The Plan says a 
unilateral open endovascular revascularization of femoral artery with transluminal stent placement and 
atherectomy 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 a unilateral open endovascular 
revascularization of femoral artery with transluminal stent placement and atherectomy. Our reviewer says that a 
unilateral open endovascular revascularization of femoral artery with transluminal stent placement and 
atherectomy is not medically necessary. Our physician reviewer found that there is no documented disease of 
the femoral artery. Therefore, the requested procedure on the right femoral artery is 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 a unilateral open endovascular revascularization of femoral artery with 
transluminal stent placement and atherectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a unilateral open endovascular revascularization of femoral artery with transluminal stent 
placement and atherectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
December 5, 2022, to December 8, 2022, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the
medical records support that the DRG originally billed was supported. The Plan denied your request. The Plan
says that the billed diagnosis of Other specified sepsis (A41.89) is not supported by the medical record.

Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. In this case, you billed the inpatient services provided with diagnosis
coded, A41.89, defined as Other specified sepsis. Our Medical Director states that the enrollee had a medical
history that included heart disease. The enrollee presented to the hospital on December 5, 2022, with
respiratory distress. He was febrile, tachycardic, tachypneic, and hypoxic. A chest X-ray demonstrated
cardiomegaly. Testing for influenza A was positive. The enrollee was diagnosed with sepsis likely from
influenza A and acute hypoxic respiratory failure. Treatment with Tamiflu and empiric antibiotics was
initiated. On December 8, 2022, the acute hypoxic respiratory failure had resolved. Bacterial infection was
unlikely and was ruled out. The clinical documentation does not sufficiently support DRG 871. The removal of
diagnosis code A41.89 is appropriate. Our Medical Director found that the enrollee's condition did not meet
Medicare criteria for the inpatient hospital services provided from December 5, 2022, to December 8, 2022, at
the DRG originally billed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee from December 5, 2022, to December 8, 2022, at the
Diagnosis Related Group (DRG) originally billed.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 96365. We decided that the Plan does not have to pay 
for procedure code 93005.  
 
You asked the Plan to pay for the emergency room services provided on September 21, 2022. You say that the 
codes are separately payable. The Plan says that the services are packaged. 
 
We decided that the Plan has to pay for procedure code 96365.  
 
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. The file shows that the Plan has agreed to pay for code 96361, which is an 
add-on code to primary procedure code 96365. The Plan has not provided a rationale to substantiate the add-on 
being payable but not the primary procedure code. 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 procedure code 96365.  
 
We also decided that the Plan does not have to pay for procedure code 93005. 
 
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 code 93005 has a status indicator of Q1. Code 93005 is not 
separately payable when reported on the same claim as a status indicator of V, such as billed code 99285. 
Therefore, we decided that the Plan does not have to pay for procedure code 93005. 
 
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.