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

 
We decided that the Plan does not have to pre-approve percutaneous revascularization (37225, 37226, 37224, 
36247, 37227). 
 
You asked the Plan to pre-approve percutaneous revascularization. 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 follows Medicare rules. Medicare rules say that PTA is covered when used under certain conditions. 
 
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 percutaneous revascularization. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, there are 
no ankle brachial indexes (ABIs) are provided. No computed tomography (CT) angiogram or magnetic 
resonance angiography (MRA) is provided. The enrollee is not on medical therapy with Cilostazol. There is no 
documentation of participation in supervised exercise program. The review has determined that the enrollee 
does not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous revascularization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve percutaneous revascularization (37225, 37226, 37224, 36247, 37227).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (85018, 85014, 85652, 85025) provided on 
June 22, 2020. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim processed at the in-
network level. The Plan denied your request. The Plan says the corrected claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until June 1, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services (85018, 85014, 85652, 85025) provided on June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92134 billed for date of service September 
27, 2022. 
 
You asked the Plan to pay for procedure code 92134. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed with a 
diagnosis code which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that there are certain diagnosis codes which support the medical necessity of code 92134.  
 
 We looked at the file and Medicare rules. Specifically, the diagnosis codes billed on this claim are not included 
on the list of appropriate diagnosis codes to support the medical necessity of CPT code 92134. Based on this 
information, we decided that Medicare rules for coverage of procedure code 92134 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 92134 billed for date of service 
September 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography (74261). 
 
You asked the Plan to pre-approve a CT colonography. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet coverage criteria for the requested service. 
 
The Plan follows Medicare rules. Medicare rules say that CT colonography is indicated in those patients in 
whom a diagnostic optical colonoscopy of the entire colon is incomplete, or when an optical colonoscopy 
cannot be safely attempted, or for the evaluation of a submucosal abnormality detected on colonoscopy or other 
imaging study. 
 
   
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 based on the medical records provided there is no documentation that the CT colonography at issue in this 
case meets all Medicare criteria for medically reasonable and necessary for the enrollee. Our physician 
reviewer found the provided records do not document that the colonoscopy performed on January 24, 2023, 
was incomplete or that optical colonoscopy cannot be safely attempted or that CT colonography is indicated for 
the evaluation of a submucosal abnormality detected on colonoscopy or other imaging study as required by the 
Local Coverage Determination (LCD). 
 
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 computed tomographic (CT) colonography (74261).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that you feel this enrollee is an 
excellent candidate for this minimally invasive procedure and should have access based on medically necessity 
and strong level 1 clinical evidence supporting the efficacy and safety of this procedure. The Plan denied your 
request. The Plan says the procedure is considered experimental and investigational as there are not enough 
studies to show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion device (22869).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service September 
24, 2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the claim was correctly coded and should be 
paid. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for code 
70551. 
 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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service September 24, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 25, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice on 
the date of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on May 18, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance services 
provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for take-home supplies of methadone (code G2078) provided on 
October 3, 2022. 
 
You asked the Plan to pay for take-home supplies of methadone. The Plan denied your request. The Plan says 
individual providers cannot bill for OTP services. Payment is not allowed for this claim because it does not 
meet the opioid treatment program criteria for payment. Per CMS, we can only pay opioid treatment program 
claims for SAMHSA certified provider. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of take-home supplies of methadone have not been met. Therefore, we decided that the Plan does not 
have to pay for take-home supplies of methadone (code G2078) provided on October 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electrophysiologic study and catheter ablation (CPT 
code(s): 93462, 93613, 93621, 93622, 93623, 93653, 93655 and 93662). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says catheter ablation is only necessary for documented arrhythmias (abnormal 
fast hear beats). The Plan states your monitor did not show any arrhythmias. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient documentation to support the medical necessity for the requested service in 
your clinical management. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the electrophysiologic study and catheter ablation (CPT code(s): 93462, 93613, 93621, 
93622, 93623, 93653, 93655 and 93662).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing care provided on July 5, 2022. 
 
You asked the Plan to pay for the nursing care. You say that the claim was denied for timeliness, and the 
services were medically necessary. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing care provided on July 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service February 24, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that you disagree 
with the denial. The Plan denied your request. The Plan says these codes are included in the skilled nursing 
facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88341, 88342, 88360 and 88381 have a Professional/Technical indicator of 1. This means 
that CPT codes 88341, 88342, 88360 and 88381 have both a professional and technical component. In this 
case, CPT codes 88341, 88342, 88360 and 88381 have not been billed with an appropriate modifier to indicate 
the professional component. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service February 24, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 7, 2022, to July 8, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee was discharged from hospice on July 2, 2022 
and did not go back onto hospice until July 9, 2022. The Plan denied your request. The Plan says the original 
Medicare is responsible for payment. 
 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 2, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for SNF care provided from 
July 7, 2022, to July 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for subsequent hospital care (code 99232) provided on July 7, 2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the patient was seen by two different 
providers of different specialties on the same date of service. The Plan denied your request. The Plan says that 
the payment for this service is included in the fee for the procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for subsequent hospital care 
(code 99232) provided on July 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services rendered on July 31, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 11 for an 
office. This POS is inappropriate for the billed services. Therefore, we decided that the Plan does not have to 
pay for the remote monitoring services rendered on July 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by a tertiary care 
provider. 
 
You asked the Plan to pre-approve the tertiary care services. You say that the enrollee has been seeing this 
surgeon since July 2022. The Plan denied your request. The Plan says the enrollee's records do not describe a 
medical problem that needs to be managed or treated by a tertiary care provider. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 tertiary care services. Our physician reviewer found the provided 
records do not document any patient factors or complications which would require treatment by the out-of-
network tertiary care colorectal surgeon as opposed to treatment by an equally qualified and board-certified in-
network colorectal surgeon.  
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 tertiary care services have not been met.  
 
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 the tertiary care services. Therefore, we decided that 
the Plan does not have to pre-approve the office services to be provided by a tertiary care provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unspecified iron 
deficiency anemia. The enrollee has not tried and failed the Plan's required drugs, Infed and Venofer. The 
records do not show that the required drugs would be less effective or have adverse effects; therefore, Injectafer 
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 Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
July 11, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service July 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
April 16, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this service was billed with 
diagnosis G46.4 (cerebellar stroke syndrome). This diagnosis is a secondary only diagnosis; however, this 
diagnosis was billed as the first-listed diagnosis. This claim is not payable as billed. Based on this information, 
we decided that Medicare rules for coverage of the emergency department visit have not been met.  Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 
provided on April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization, endovascular, open or percutaneous, 
tibial/peroneal artery, unilateral (37230) and revascularization, endovascular, open or percutaneous, femoral, 
popliteal artery(s), unilateral (37226) provided August 15, 2022. 
 
You asked the Plan to pay for the inpatient surgery services. You say that please review and reprocess 37230 
and 37226 for payment. The Plan denied your request. The Plan says the services of an assistant surgeon, co-
surgeon, or surgical team are not covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 37230 and 37226. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is 
not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage 
criteria for the inpatient surgery services have not been met. Therefore, we decided that the Plan does not have to pay for the revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral (37230) 
and revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral (37226) 
provided August 15, 2022.