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

 
We decided that the Plan does not have to pay for a drug test, definitive, 22 or more classes (G0483) provided 
on July 25, 2022.  
You asked the Plan to pay for a drug test, definitive, 22 or more classes. You say that this testing was 
determined to be medically necessary by the treating provider. The Plan denied your request. The Plan says 
under Medicare rules, the requested number of definitive urine drug classes are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a drug test, definitive, 22 or more classes. 
Our reviewer says that the definitive drug testing of 22 or more classes was not medically necessary. Our 
physician reviewer found that the reviewed documentation indicates that the diagnosis is medication 
management of long term (current) drug therapy. The medical record sent by the provider shows a definitive 
urine drug testing (UDT) panel for multiple drug classes was performed, but does not show screening test 
results which are positive or inconsistent with prescription medications, dosing schedules, or history and 
expected results. The Medicare rules say definitive testing is covered only under certain conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a drug test, definitive, 22 or more classes have not been met. Therefore, we 
decided that the Plan does not have to pay for a drug test, definitive, 22 or more classes (G0483) provided on 
July 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that computed tomography of the enrollee's body showed 
an enlarging left adrenal gland metastasis as her only site of definite progression and that a higher dose of 
radiation should be used to improve control. The Plan denied your request. The Plan says the medical records 
do not support that the routine use of the requested therapy for the type of cancer being treated. The Plan says 
that it has not been shown that the enrollee's cancer type has responded well to the requested type of treatment. 
 
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 SBRT. Our reviewer says that SBRT 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
need for SBRT is not established versus a more standard 3D conformal radiation plan for palliation. SBRT has 
a not insignificant risk of severe or fatal toxicity such that with a goal of palliation, SBRT is not considered 
standard practice. SBRT for oligoprogression of SCLC, particularly in the setting of recently treated brain 
metastases, in not evidence based and therefore not in accordance with accepted standards of care bases. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiation Therapy (SBRT).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic/pool therapy. 
 
You asked the Plan to pre-approve aquatic/pool therapy. You say that the advantage of hydrotherapy is that it is 
done in a pool that is warmer than body temperature, and the buoyancy of the water allows you to essentially 
become weightless. You also say that you would like additional sessions approved because you have been able 
to strengthen your core as well as your limbs, and have been able to reduce your pain level to a large degree. 
The Plan denied your request. The Plan says you have demonstrated in-clinic that you are able to tolerate land 
based physical therapy. The Plan also says you have 20 aquatic/pool therapy visits, and on-going aquatic/pool 
therapy is not medically indicated. 
 
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 aquatic/pool therapy. Our reviewer says 
that aquatic/pool therapy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found you began therapy in December 2020 for low back pain, and were denied continued therapy in 
October 2022. Your range of motion remained at 100% flexion but impaired extension and lateral rotation, 
without change. Our reviewer found that you are able to do a home exercise program. Our physician reviewer 
also found that there is no evidence that continued input from a skilled therapist is 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 aquatic/pool therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve aquatic/pool therapy.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the right shoulder, without 
contrast (73221). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that the enrollee was being treated for 
pain in the right shoulder. He presented with persistent right shoulder pain that is moderate and has an aching 
quality. The exam of the right shoulder reveals a range of motion of external rotation 80 both active and 
passive and flexion 160 active and 165 passive. There is a positive empty can test, Hawkins, and Neers 
testing. The strength is abnormal in the right external rotation and supraspinatus. In this case, the enrollee has 
tried and failed conservative treatments including injections and physical therapy. He notes ongoing subjective 
symptoms and objective deficits of the right shoulder. The x-rays provided were non-diagnostic. Therefore, the 
requested MRI of the right shoulder, in this case, is medically reasonable and 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 this service have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the right shoulder, without contrast (73221).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) provided 
to the enrollee on June 16, 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 provider did not bill as required 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. 
 
This code was billed on the same day as CPT 43762, which is inappropriate, as the global surgery period for 
this procedure is 10 days. 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 emergency room 
services (procedure code 99284) provided to the enrollee on June 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided on October 25, 2021. 
 
You asked the Plan to pay for the emergency services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the emergency services have been met. 
There was no documentation received for this claim to indicate services were unrelated. Therefore, we decided 
that the Plan does not have to pay for the emergency services provided on October 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Viable Disc Nucleus Pulposus (NP) Tissue Allograft 
(0627T). 
 
You asked the Plan to pre-approve the Viable Disc Nucleus Pulposus (NP) Tissue Allograft. You say that the 
service is medically necessary. The Plan denied your request. The Plan says though the patient has a history of 
continued low back pain, the requested procedure is considered investigational. There have not been large 
enough studies to support efficacy and safety. 
 
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 Viable Disc Nucleus Pulposus (NP) 
Tissue Allograft. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the procedure is considered experimental/ investigational 
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 Viable Disc Nucleus Pulposus (NP) Tissue Allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve the Viable Disc Nucleus Pulposus (NP) 
Tissue Allograft (0627T).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for critical care services (99291) billed for dates of service September 17, 
2022, and September 18, 2022. 
 
You asked the Plan to pay for critical care services. You say that this was not a duplicate claim, and these 
services are supported in the medical records. The Plan denied your request. The Plan says that code 99291 has 
a medically unlikely edits (MUE) value of 1, which means that no more than one unit may be billed per date of 
service. The provider in this case billed 2 units, exceeding the MUE. 
 
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 claim provided shows that you billed one unit of 99291 for 
September 17, 2022, and one unit of 99291 for September 18, 2022. There is no evidence provided to show that 
any other units of 99291 were billed for these dates, and there is no evidence to show that this claim is a 
duplicate of another claim which has already been paid by the Plan. One unit of 99291 per date of service does 
not exceed the MUE for this code. The Plans denial is not substantiated in this case. Therefore, we decided 
that the Plan has to pay for critical care services (99291) billed for dates of service September 17, 2022, and 
September 18, 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 subsequent hospital care service (procedure code 99231) 
billed for date of service October 28, 2021. 
 You asked the Plan to pay for procedure code 99231. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Review of the claims history shows the exact same service (99231) was 
already billed by the provider for the same date of service. You did not provide all the required evidence 
showing that the excess units were actually provided, were correctly coded, and were medically necessary. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99231 have not been 
met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care service 
(procedure code 99231) billed for date of service October 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99296 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code 99296. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99296 is bundled into payment for code 99220. 
 
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 99296 
is a column II code to column I code 99220 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99296 billed for date of service July 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of an IRF admission. 
 
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 clinical documentation shows that you have comorbidities and functional 
impairments; however, there are no active medical comorbidities or complex functional deficits specified, 
thus the complexity of your documented nursing, medical and rehabilitation needs would not be expected to 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a colonoscopy (45385) provided on August 24, 2022. 
 
You asked the Plan to pay for the colonoscopy. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the records do not support the billed service. 
 
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 45385 is Flexible colonoscopy with removal of polyp/tumor/lesion with snare technique. 
 
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 colonoscopy. Our reviewer says that the records support 
the service billed. Our reviewer found the record includes a colonoscopy with snare. A polypectomy was 
performed using a cold snare. The resection was complete and the polyp tissue was completely retrieved. 
 
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 colonoscopy have been met. Therefore, we decided that the Plan has to pay 
for a colonoscopy (45385) provided on August 24, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on January 4, 2022, to January 7, 
2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for inpatient hospital services at the DRG originally billed. You say that the services 
and diagnoses on this claim were reported appropriately and are supported as billed. The Plan denied your 
request. The Plan says that the medical records submitted do not support the principal diagnosis of nausea and 
vomiting, unspecified (R11.2). Therefore, the DRG rate for this claim has been changed appropriately. 
 
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 case file sent by the Plan does not include any of the medical 
records used to reach their decision. Without medical records, we cannot verify whether or not the contested 
diagnosis code is supported. Therefore, we decided that the Plan has to pay for inpatient hospital services 
provided on January 4, 2022, to January 7, 2022, at the Diagnosis Related Group (DRG) originally billed.  
 
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 procedure code 99291 billed for services provided on March 
14, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided The Plan denied 
your request. The Plan says the billed code cannot be verified. 
 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. The records show that an arterial line insertion was provided on the date of service at issue. 
However, the records provided do not include a critical care evaluation and management service for this date. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for services 
provided on March 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (CPT code J7327). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says tier exceptions reviews are not available for Part B drugs. 
 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 the medication have not been met. You cannot get a tiering 
exception for very high-cost drugs on a specialty tier. The information we have says this is a very high-cost 
drug on a specialty tier. You dont qualify for a tiering exception per Medicare rules. Therefore, we decided 
that the Plan does not have to pre-approve Monovisc (CPT code J7327).