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

 
We decided that the Plan has to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that a CT scan is medically necessary. The Plan denied 
your request. The Plan says that the criteria for a CT scan has not been met. 
 
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 scan. Our reviewer says that the 
criteria for a CT scan has been met. Our physician reviewer found that during an encounter on March 23, 2023, 
an enlarged left groin lymph node was palpated, no night sweats but some weight loss was documented. The 
presence of groin lymphadenopathy is a valid reason for CT of the abdomen and pelvis. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan.  
 
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 procedure codes 41150 and 42894 rendered on August 11, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 of the denied codes is: 
 
CPT 41150: 
 
Glossectomy; composite procedure with resection floor of mouth and mandibular resection, without radical 
neck dissection 
 
CPT 42894: 
 Resection of pharyngeal wall requiring closure with myocutaneous or fasciocutaneous flap or free muscle, skin, 
or fascial flap with microvascular anastomosis. 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support the use of procedure code 41150, as there is a more appropriate code that can be used that is better 
equipped with the medical documentation. Additionally, the medical records do not support the use of CPT 
42894, as there was no resection of the pharyngeal wall. 
 
We looked at this coder'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 pay for procedure codes 41150 and 42894 rendered on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve injection. You say that the enrollee needs this injection. The Plan denied 
your request. The Plan says the injection 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 injection. Our reviewer says that the 
sacroiliac joint injection is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not support a diagnosis of sacroiliitis. Therefore, the reviewer 
found that the requested injection 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 injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sacroiliac joint injection (27096).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (14301, 14302) provided on September 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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 14301 is "Adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm". The CPT Code Manual definition of code 14302 is "Adjacent tissue 
transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to 
code for primary procedure)". 
 
We asked our coder 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 services. Our reviewer says that the use of code 14301 
and 14302 is not supported by the records provided. Our reviewer found that incision and re-approximation of 
the breast tissue are inherent components of the main mastopexy procedure. There is no evidence that a 
separate tissue transfer and rearrangement that was not part of the mastopexy was performed.  
We looked at this coder'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 pay for the services (14301, 14302) provided on September 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that after a traumatic hip fracture you need IRF services 
in order to regain maximum function. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 14-day sensor. The Plan denied your request. The Plan 
says the enrollee does not meet the prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 14-day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physician office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a physician office visit. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON care have 
not been met. 
 
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 
a physician office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has no chest pain or 
other cardiac symptoms after coronary artery bypass graft (CABG) surgery. There is no evidence that the 
electrocardiogram (ECG) is uninterpretable. The records do not support the rationale for the invasive imaging 
study. The guidelines do not support a need for cardiac catheterization in this setting and the services are not 
reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cardiac catheterization.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyvgart. 
 
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 not tried and failed the 
Plan's required drugs, a trial of two immunosuppressants. The records do not support that the required drugs 
would be contraindicated or less effective; therefore, Vyvgart 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 Vyvgart.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on July 15, 2022. 
 
You asked the Plan to pay for outpatient services. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says a female-only procedure was billed on this claim for a 
male patient. This claim must be corrected and resubmitted for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that if the sex of the patient does 
not match the sex designated for a procedure code reported on an outpatient claim, the entire claim is returned 
to the provider for correction. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient services have not been met. Specifically, the codes submitted on this claim includes 
CPT code 81025 (urine pregnancy test, by visual color comparison methods). Code 81025 is indicated as a 
female-only procedure. However, the enrollee in this case is male, which means that the sex of the patient does 
not match the sex designated for this procedure code. Therefore, I/OCE Edit 8 applies and this entire claim is 
rejected to be returned to the provider for correction. Therefore, we decided that the Plan does not have to pay 
for outpatient services provided on July 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 03, 2022, 
through August 08, 2022, and billed with diagnosis codes A41.9 and J96.21. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis A41.9 and J96.21 is supported by the records. The Plan denied your request. The Plan says 
the documentation submitted does not support secondary diagnosis of A41.9 and J96.21. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis codes A41.9-Sepsis 
Unspecified Organism and J96.21-acute and chronic respiratory failure with hypoxia. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the documentation does not support the secondary diagnosis of A41.9-Sepsis and J96.21-
Acute and chronic respiratory. Our physician reviewer found the member was hospitalized with, treated for, 
and discharged with a diagnosis of pneumonia.  The member is noted to use nocturnal oxygen at baseline, and 
to have a history of pulmonary embolism (PE) resulting in a cardiac arrest with shock liver. There is no 
evidence that the member had sepsis, cardiovascular instability, acute respiratory failure, or acute organ 
dysfunction during this hospitalization. Therefore, secondary diagnosis codes A41.9 and J96.21 are not the 
appropriate secondary diagnosis.  
 
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 on August 03, 2022, through August 08, 2022, and billed with 
diagnosis codes A41.9 and J96.21.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 20610, 77002, J7328, and Q9965 rendered on May 12, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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 
the denied codes is: 
 
CPT 20610: 
 
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); 
without ultrasound guidance 
 
CPT 77002: 
 
Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List 
separately in addition to code for primary procedure) 
 
Healthcare Common Procedure Coding System (HCPCS) J7328: 
 
Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg 
 
HCPCS Q9965: 
 
Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the medical records support the use of 
the procedure codes listed above. There was fluoroscopic guidance used needle placement for the injection into 
the left knee, the material injected was supported by the HCPCS J7328 and the contrast material used for the 
fluoroscopy was captured by Q9965. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 20610, 77002, J7328, and Q9965 rendered on May 12, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Trulicity injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Trulicity is a self-administered drug and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Trulicity injection.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 although further rehabilitation services would be appropriate to improve function, as 
a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. 
 
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.