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

 
We decided that the Plan does not have to pay for ambulance mileage (A0425) provided January 14, 2022. 
 
You asked the Plan to pay for the ambulance mileage. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim is a duplicate. 
 
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 code A0425 is not supported in the medical record. Specifically, Ambulance mileage for this 
service was already paid under previous claim 4527015900KLC. The ambulance transport (A0428) denial was 
overturned by the plan. Based on this information, we decided that Medicare rules for coverage of the 
ambulance mileage have not been met.  
 
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for ambulance mileage (A0425) provided January 14, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Part B injectable services provided on September 21, 2021. 
 
You asked the Plan to pay for the Part B injectable services. You say that the provided services were medically 
necessary. The Plan denied your request. The Plan says that they were unable to make a determination within 
the allotted time frame. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan did not provide any supporting evidence based on Medicare 
criteria why the services provided were not payable. Therefore, we decided that the Plan has to pay for the Part 
B injectable services provided on September 21, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood bank services (86077) January 21, 2022. 
 
You asked the Plan to pay for the blood bank services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the allowable. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the blood 
bank services have not been met. Therefore, we decided that the Plan does not have to pay for blood bank 
services (86077) January 21, 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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 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 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 pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve an SI joint injection. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an SI joint injection. 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, there is no documentation on physical examination of three (3) or more 
positive tests results. The clinical value and effectiveness of an SI joint injection in the absence of tenderness 
and negative provocative testing results have not been demonstrated in the peer-reviewed literature. The review 
has determined that the service at issue 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 an SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopic catheterization of the biliary ductal system 
(74328) provided on February 14, 2022. 
 
You asked the Plan to pay for endoscopic catheterization of the biliary ductal system. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim 
has not been billed appropriately based on Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay any provider or supplier other 
than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for endoscopic catheterization of the biliary ductal system (74328) 
provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99358, 99497) provided October 10, 
2021 to October 11, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of codes 99358 & 99497 are prolonged evaluation and 
management service before and/or after direct patient care; first hour, and advance care planning service. 
 
We find that CPT code 99358 & 99497 is not supported in the medical record. Specifically, insufficient 
documentation is provided to support these codes. The records do not note how much time was spent on each 
service. The records do not document a discussion of end-of-life decisions and preferences. Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99358, 99497) provided 
October 10, 2021 to October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zip Fusion device. 
 
You asked the Plan to pre-approve a Zip Fusion device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Zip Fusion device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the zip fusion device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Zip Fusion device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Zip Fusion device.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from December 22, 2021, to 
December 31, 2021. 
 
You asked the Plan to pay for the home health services. 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. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the occupational therapy evaluation on December 23, 2021, 
contradicts the submitted Outcome and Assessment Information Set (OASIS) data. The Plan has not provided 
enough information to support this as a reason to deny payment based on Medicare criteria as the medical 
records support the services as billed. Therefore, we decided that the Plan has to pay for the home health 
services provided from December 22, 2021, to December 31, 2021.  
 
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 pay for the assistant at surgery services provided on December 22, 
2021. 
 
You asked the Plan to pay for the assistant at surgery 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 say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services 
provided on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee (L5828 + L5845 + L5848 + 
L5850 + L5856 + L5925). 
 
You asked the Plan to pre-approve a microprocessor knee. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 microprocessor knee. Our reviewer 
says that the item is not medically necessary Our physician reviewer found the physician documentation does 
not reveal that the patient's functional needs are unable to be met with a mechanical knee 
 
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 microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee (L5828 + L5845 + L5848 + L5850 + L5856 + L5925).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services (99283) provided on September 29, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that they were unable to make a 
determination within the allotted time frame. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has provided no supporting evidence that shows these 
services were already paid for on another claim. Therefore, we decided that the Plan has to pay for the 
emergency room services (99283) provided on September 29, 2021.  
 
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 pay for the critical care services (99291) provided on October 23, 
2021. 
 
You asked the Plan to pay for the critical care services (99291). 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 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. 
 
In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based 
code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent 
providing services to the enrollee. The progress notes for October 23, 2021, does not note how much time was 
spent providing services to the enrollee. As such, the provided documentation does not support the billing of 
code 99291. Based on this information, we decided that Medicare rules for coverage of the critical care services (99291) have not been met. Therefore, we decided that the Plan does not have to pay for the critical care 
services (99291) provided on October 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the harness (E2313), expandable controller (E2377), 
electronic connection (E2311). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are 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 the wheelchair accessories. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the member does have use of the upper extremity and can operate and control the 
power options using the switches that are included in the basic wheelchair. 
 
 
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 wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the harness (E2313), expandable controller (E2377), electronic connection 
(E2311).
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's medical management and rehabilitation 
needs require an inpatient rehabilitation stay and close physician supervision. The Plan denied your request. 
The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care 
such as at a skilled nursing facility. 
 
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 says the enrollee was admitted for surgical management of colon cancer and uterine 
fibroids. Our physician reviewer found there are no complex nursing or rehabilitation needs. Medical problems 
are stable. While you have a need for physical or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insulin pump (E0784). 
 
You asked the Plan to pre-approve an insulin pump. You say that the requested insulin pump is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for an insulin pump have not 
been met. 
 The Plan follows Medicare rules. Medicare rules say that for an insulin pump to be covered, an enrollee must 
have a fasting C-peptide level that is less than or equal to 110% of the lower limit of normal of the laboratory's 
measurement or 200% of the lower limit of normal for patients with renal insufficiency 
 
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 insulin pump. Our reviewer says that 
this insulin pump is not medically reasonable and necessary per the Medicare rules. Our physician reviewer 
found the review indicates that the enrollee has diabetes mellitus 2 compliant with insulin dosing, uses Dexcom 
continuous glucose monitor. The member also takes Jardiance and Ozempic 0.5 mg. At this time, the member 
is having hypoglycemia when the member is active in the daytime and history of hospitalization at the end of 
2021 for chronic obstructive pulmonary disease exacerbation, with episode of hypoglycemia since that time. 
The updated fasting C-peptide testing requirement states the following: fasting C-peptide level that is less than 
or equal to 110% of the lower limit of normal of the laboratory's measurement or 200% of the lower limit of 
normal for patients with renal insufficiency. Based on the additional information available, the request does not 
meet the Medicare or health plan coverage criteria. 
 
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 insulin pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an insulin pump (E0784).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82656, 83520, 83631, 87177, 87209) provided 
October 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed services are not supported in the documentation provided. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (82656, 83520, 83631, 87177, 87209) provided October 10, 
2021.