Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care 
provided from June 6, 2021, to June 8, 2021. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the billing of secondary 
diagnosis code, K85.90, is supported. The Plan denied your request. The Plan says the provided documentation 
does not support the billing of secondary diagnosis code, K85.90. 
 
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 code, K85.90, defined as Acute 
pancreatitis without necrosis or infection, unspecified. 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 an additional amount for the inpatient care. Our reviewer says that the billing of secondary diagnosis code, 
K85.90 is not supported. Our physician reviewer found the provided documentation does not indicate the 
clinical and laboratory testing did not indicate evidence of pancreatic or peri-pancreatic inflammation. The 
reviewer found that the enrollee's symptoms improved with steroid administration in the setting of suspected 
colitis. Therefore, the reviewer found that the provided documentation does not support the billing of secondary 
diagnosis code, K85.90, Acute pancreatitis without necrosis or infection, unspecified.  
 
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 
an additional amount for the acute inpatient hospital care provided from June 6, 2021, to June 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosopt PF eye drops. 
 
You asked the Plan to pre-approve Cosopt PF. You say that you need this drug. You also say that you are 
allergic to preservatives. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 Cosopt PF eye drops.  
 Benefits for Cosopt PF 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
level; lumbar (with lateral transverse technique, when performed) (CPT code 22612) and arthrodesis, posterior 
or posterolateral technique, single level; each additional vertebral segment (CPT code 22614). 
 
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 the submitted records do not show failure of conservative treatment for the 
enrollee's back pain issues either. The Plan states there is no documentation or reports of imaging of the 
enrollee's spine have been submitted. The Plan states Medicare criteria for reasonable and necessary are not 
met because use of this device as a minimally invasive procedure has not been shown to be safe and effective 
in long term studies. 
 
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 no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested arthrodesis, posterior or 
posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) CPT code 22612, and arthrodesis, posterior or posterolateral technique, single level, each additional vertebral segment 
CPT cod 22614, in this case, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral 
transverse technique, when performed) (CPT code 22612) and arthrodesis, posterior or posterolateral 
technique, single level; each additional vertebral segment (CPT code 22614).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood smear (85060) provided on November 30, 2021. 
 
You asked the Plan to pay for a blood smear. You say that this was medically necessary. The Plan denied your 
request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients. 
 
We looked at the file and Medicare rules. The record shows that code 85060 was billed as an outpatient service 
in this case. Based on this information, we decided that Medicare rules for coverage of a blood smear have not 
been met. Therefore, we decided that the Plan does not have to pay for a blood smear (85060) provided on 
November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the requested item to 
prevent ulcers from forming per your medical treatment plan by your surgeon. The Plan denied your request. 
The Plan says you do not have any open venous stasis ulcers on either lower extremity; therefore, the requested 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) provided on February 4, 2022. 
 You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says separate payment cannot be made for this 
service 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, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 the computed tomography (CT) scan of the head or brain (70450) 
provided on February 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract eye surgery (CPT code 66984) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says this service is available by a provider in the enrollee's 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 eye surgery (CPT code 66984) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Genetic Testing for Myeloproliferative Disease 
(testing for blood disorders) including JAK2 V617F, MPL, JAK2 Exon 12, CALR and CSF3R testing (CPT 
code(s): 81219, 81479, 81339, 81279). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because your records show that you do not meet 
the requirements for JAK2 V617F testing, and therefore do not qualify for the additional cascading reflex 
testing. 
 
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 physician reviewer 
found the utility of this testing is not clear as clinically and based on other completed testing myeloproliferative 
disorder is not likely, making JAK2 testing not clinically relevant. Also, the other genetic tests included in this 
panel would not directly lead to a change in treatment based on the overall clinical picture. Therefore, this 
request for genetic testing will be considered not 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 
the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Genetic 
Testing for Myeloproliferative Disease (testing for blood disorders) including JAK2 V617F, MPL, JAK2 Exon 
12, CALR and CSF3R testing (CPT code(s): 81219, 81479, 81339, 81279).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic mammogram rendered on January 26, 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 are not covered. 
 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 77065 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 these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic 
mammogram rendered on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) infusion provided on December 4, 2021 
to December 16, 2021 by an out-of-network (OON) provider. 
 
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 rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the intravenous (IV) infusion provided on 
December 4, 2021 to December 16, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered by the Plan. 
 
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 Methotrexate for the 
enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain without 
contrast (70450) provided on March 3, 2022. 
 
You asked the Plan to pay for CT of the head or brain. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 70450 
is a column II code to column I code 70496. 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 computed tomography (CT) of the head or brain without contrast 
(70450) provided on March 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on August 26, 2021. 
 
You asked the Plan to pay for physical therapy services. You say that the medical records required to reprocess 
the denied claim are attached. The Plan denied your request. The Plan says the code is not appropriate for the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a preventive medical visit (99396) and 
related services provided by an out-of-network provider on January 17, 2022. 
 
You asked the Plan to waive the coinsurance for a preventive medical visit. You say that you are being balance 
billed for a preventive visit. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for an annual wellness visit with an out-of-network provider.  
 
You have been asked to pay $49.55, or 50% of the Medicare-allowed charge of $99.11, for a preventive 
medical visit. A preventive medical visit falls within the "Annual wellness visit" benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for a preventive medical visit (99396) and related services provided by 
an out-of-network provider on January 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services provided on June 11, 
2020. 
 
You asked the Plan to pay for the ER services. You say that the services should be covered. The Plan denied 
your request. The Plan says the member was seen by two physicians in the same group and billed for the same 
service on same date. 
 
The Plan must follow Medicare rules. Medicare rules say that Physicians in the same group practice who are in 
the same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ER services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services provided on 
June 11, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the smoking cessation services provided on February 17, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that only two 
counseling quit attempts within a 12-mont period are covered. 
 
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 received the services at issue by a contract provider. The file does not show that the plan 
provided notice that the services would not be covered. Under Medicare rules, this means the services are 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the smoking cessation 
services provided on February 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on January 6, 2022. 
 
You asked the Plan to pay for the services provided. You say that the records document evidence of medical 
necessity. The Plan denied your request. The Plan says the claim was reported without a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. We find that CPT 85060 code was not billed with an appropriate modifier. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the pathology services provided on January 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the documentation does not support that the enrollee has an accepted 
medical indication for the use of the requested drug, Keytruda. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested drug, Keytruda, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
reviewer found that the Medicare approved cancer drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested 
drug, Keytruda 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.