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

 
We decided that the Plan does not have to pre-approve endovenous ablation (36478). 
 
You asked the Plan to pre-approve endovenous ablation. You say that the enrollee demonstrates C2,3EPASPR 
classification for chronic venous insufficiency. The Plan denied your request. The Plan says the records do not 
indicate the enrollee has any qualifying symptoms. 
 The Plan follows Medicare rules. Medicare rules say that coverage of endovenous ablation therapy is limited to 
patients with a maximum vein diameter of 12 millimeters (mm) for polidocanol microfoam (PEM), 
cyanoacrylate embolization (CAE) ablation, and mechanochemical ablation (MOCA), and the absence of 
thrombosis or vein tortuosity, which would impair catheter advancement. 
 
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 endovenous ablation. Our reviewer says 
that the request for endovenous ablation is not medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollee has varicose veins. The reviewer found that the provided 
documentation is insufficient to establish that the enrollee has at least one of the required elements of 
symptoms. Therefore, the reviewer found that the request for endovenous ablation 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 endovenous ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous ablation (36478).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151), home health 
occupational therapy (G0152), and home health skilled nursing (G0299). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. After the therapy 
treatments already provided and recently approved, records do not support that the complexity of the enrollee's 
conditions are such that the skills of a professional therapist are required to achieve further improvement in the 
enrollee's symptoms or functional status. Further utilization of the home exercise program and/or transition to 
outpatient therapy appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (G0151), home health occupational therapy 
(G0152), and home health skilled nursing (G0299).
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 please approve transfer so that the 
enrollee is able to get the care that they not only need but deserve. The Plan denied your request. The Plan says 
the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 record indicates that the enrollee remains critically ill with acute medical issues 
and still requires acute care services. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87652 and 87900 provided on March 29, 2023. 
 
You asked the Plan to pay for procedure codes 87652 and 87900. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
supported as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for procedure codes 87652 and 87900 by a contract provider. The file does not show 
that the plan provided notice that procedure codes 87652 and 87900 would not be covered. Under Medicare 
rules, this means procedure codes 87652 and 87900 are considered approved by the plan. Therefore, we 
decided that the Plan has to pay for procedure codes 87652 and 87900 provided on March 29, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve cataract surgery with an out-of-network provider. You say that you want the 
Plan to approve the service with this provider. The Plan denied your request. The Plan says this provider is out-
of-network. The requested service is available in-network. 
 
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 
cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service May 17, 
2023. 
 
You asked the Plan to pay for procedure code 93976. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 93976 is bundled into payment 
for code 37191. 
 
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 93976 
is a column II code to column I code 37191. 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 93976 billed for date of service May 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are requesting reconsideration 
based on medical necessity. The Plan denied your request. The Plan says the service requested does not meet 
the requirements for approval. 
 
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 services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) evident in the case record that shows 
only modic changes without facet degenerative joint disease (DJD) or foraminal stenosis. The cause of pain is 
not clear.  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 Intracept procedure (64628, 64629).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 
26, 2023. 
 
You asked the Plan to pay for the ED services. You say that your organization is not enrolled with Medicare. 
The Plan denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan follows Medicare rules. The rules a PCD coded as E0675 to treat peripheral arterial disease is not 
eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the ankle. 
 
You asked the Plan to pre-approve an MRI of the ankle. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says you do not meet the criteria for an MRI of the ankle.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the ankle. Our reviewer says 
that the requested imaging is not medically necessary. Our physician reviewer found that there is no 
demonstration of the requested MRI of the left ankle. There are no plain films and no attempt at conservative 
therapy for ankle symptoms. 
 
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 MRI of the ankle have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the ankle.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 18, 2022, 
to December 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted timely. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from December 18, 2022, to 
December 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be transferred to a 
long-term acute care hospital to regain maximum/prior level of functioning. The Plan denied your request. The 
Plan says the enrollee's records do not show the need for continued treatments and care that can only be given 
in a hospital setting, continued care needs include oxygen weaning and rehabilitation. 
 
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 is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 13, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee is dual-eligible and you are 
trying to get an exact denial reason. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 8, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on February 13, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS cytopathology and histopathology diagnostic 
testing (88361, 88312, 88305, and 88112) provided on October 17, 2022. 
 
You asked the Plan to pay for the WATS cytopathology and histopathology diagnostic testing. You say that 
this testing was medically necessary. The Plan denied your request. The Plan says screening for Barrett's 
esophagus is not a covered screening service. 
 
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 pay for the WATS cytopathology and 
histopathology diagnostic testing. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that WATS cytopathology and 
histology with Barrett's esophagus screening does not meet the medical necessity criteria outlined. 
 
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 WATS cytopathology and histopathology diagnostic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the WATS cytopathology and histopathology 
diagnostic testing (88361, 88312, 88305, and 88112) provided on October 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x9), and home 
health clinical social worker (G0155 x2). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you are noted 
to have stable vital signs. You do not require wound care, catheterization, G-tube feeding, or administration of 
intravenous (IV) or complex medications. You are modified independent to requiring some assistance with 
daily activities. You are noted to have caregiver support and there has been education regarding your condition 
and medications. You have not recently had a change in your baseline medical conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299 x9), and home health clinical social worker 
(G0155 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen 
concentrator.  
You asked the Plan to pre-approve the oxygen concentrators. You say that the medical records support the 
medical necessity for the oxygen and portable oxygen concentrators. The Plan denied your request. The Plan 
says the details we got from your doctor don't meet Medicare guidelines that show a medical reason you need 
the eight (8) month rental of an oxygen concentrator and portable oxygen.  
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 oxygen concentrators  Our 
reviewer says that the oxygen concentrators are not medically necessary. Our physician reviewer found you do 
have chronic obstructive pulmonary disease (COPD) with a history of pulmonary embolism and the 
documentation does not support the need for a home oxygen concentrator. Hence, documentation does not 
support the need for home oxygen, there is no data to support oxygen supplementation. No home oxygen 
therapy is indicated per the documentation or studies to support it's need. 
 
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 oxygen concentrators  have not been met.  Therefore, we decided that the 
Plan does not have to pre-approve an oxygen concentrator and portable oxygen concentrator.