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

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Keytruda is not Food and Drug 
Administration (FDA)-approved for the enrollee's diagnosis. Its use is not supported int he major drug 
compendia or by clinical research appearing in a Medicare-approved medical journal. The Keytruda is not safe 
and effective or reasonable and 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 Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and density inserts to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that the network providers are too far away or do 
not carry the shoes your doctor recommends. The Plan denied your request. The Plan says the services are 
available from network providers. 
 
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. The Plan confirmed the network providers 
are able to provide the requested services and is located five miles from your residence. 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 diabetic shoes and density inserts to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2022, to October 7, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that procedure code S9328 was approved for this 
provider and the claims should be reprocessed for payment. 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 code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2022, to October 7, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services (76641) provided on September 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that CPT code 76641 
exceeds the allowable UOS of 1 for the same date of service per the MAI indicator of 2 and was not billed 
correctly per the bilateral surgery indicator of 1 guidance. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that code 76641 has an MUE of 1, however, a CPT code search 
reveals that code 76641 has an MUE value of 2. Additionally, Medicare rules say that for codes with a  
bilateral surgery indicator of 1, bilateral diagnostic procedure may be reported with 1 unit of service with 
modifier RT on 1 claim line plus 1 unit of service and modifier LT on a second claim line, as was done in 
this case. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided 
that the Plan has to pay for the services (76641) provided on September 6, 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: Favorable

 
We decided that the Plan has to pay for laboratory services (0117U) provided on August 31, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test is covered by Medicare and should be 
paid. The Plan denied your request. The Plan says that insufficient medical records have been submitted to 
verify that these services were medically necessary and were billed accurately. 
 
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 any evidence to show that the necessary 
records were requested from the provider at any time. Therefore, we decided that the Plan has to pay for 
laboratory services (0117U) provided on August 31, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided July 1, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided July 
1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable wireless pulmonary artery pressure 
sensor with delivery catheter (C2624) and transcatheter implantation of wireless pulmonary artery pressure 
sensor for long-term hemodynamic monitoring (33289). 
 
You asked the Plan to pre-approve CarioMEMS. You say that the enrollee has had an abnormal massive 
parallel signature sequencing (MPSS). You say that the enrollee just received a heart catheter. You also say that 
the provider would still like CardioMEMS for the enrollee's dilated cardiomyopathy. The Plan denied your 
request. The Plan says the requested service 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 CarioMEMS. Our reviewer says that 
the requested CardioMEMS is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental at this time as additional research is needed. 
Therefore, the reviewer found that the requested CardioMEMS 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 CarioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable wireless pulmonary artery pressure sensor with delivery catheter (C2624) 
and transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic 
monitoring (33289).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95907 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code 95907. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 95907 is bundled into payment for code 95867. 
 
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 95907 
is a column II code to column I code 95867 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 95907 billed for date of service July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99233 & 99239) provided on October 30, 
2021 to November 2, 2021. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definitions of codes 99233 & 99239 are Subsequent hospital care, per day, 
for the evaluation and management of a patient, and Hospital discharge day management; more than 30 
minutes. 
 
We find that CPT code 99233 & 99239 is not supported in the medical record. Specifically, the medical record 
does not include documentation to support a second evaluation and management service was provided on this 
date of service. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services 
(99233 & 99239) provided on October 30, 2021 to November 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) described by code 
E0675 and half leg appliances rendered on July 5, 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 for E0675 will be denied as not 
reasonable and necessary.   
 
We looked at the file and Medicare rules. The services at issue are a PCD described by code E0675. These 
services are denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have 
to pay for the pneumatic compression device (PCD) described by code E0675 and half leg appliances rendered 
on July 5, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the leg. 
 
You asked the Plan to pre-approve an MRI scan of the leg. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
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 an MRI scan of the leg. Our reviewer 
says that the services are medically necessary. Our physician reviewer found a physical exam revealed no 
instability, but crepitus of the patella was noted. She had cortisone injection of left knee last encounter. As the 
physical exam of the patello femoral joint revealed crepitus and the subsequent steroid injection, the criteria for 
MRI of the left knee have been satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan of the leg have been met. Therefore, we decided that the Plan has 
to pre-approve a magnetic resonance imaging (MRI) scan of the leg.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service November 
28, 2021. 
 
You asked the Plan to pay for procedure code 71045. The Plan denied your request. The Plan says payment for 
code 71045 is bundled into payment for code 71046. 
 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 71045 
is a column II code to column I code 71046. 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 71045 billed for date of service November 28, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 6, 2022, to 
April 4, 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 NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 6, 2022. The NOA was not received by the Plan until July 9, 2021. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
March 6, 2022, to April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 18, 2022. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the 
provider did not submit progress notes that are needed in order to determine the clinical utility of the testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the ordering physicians intent that the testing be performed. Based on this information, we decided 
that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on March 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the right 
shoulder (73223). 
 
You asked the Plan to pre-approve an MRI of the right shoulder. The Plan denied your request. The Plan says 
this request does not meet the Medicare or health plan coverage criteria. 
 
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 an MRI of the right shoulder. Our 
reviewer says that an MRI of the right shoulder is not reasonable and necessary for you. Our physician 
reviewer found during the last physician encounter of October 11, 2022, the physical exam did not include any 
documented right shoulder examination. Plain x-rays were ordered and there is no result in the submitted 
records. Our reviewer found the submitted material shows no red flag to mandate an immediate MRI without 
the x-ray results and a 6-week trial of conservative management. Our physician reviewer also found that the 
medical necessity of the requested MRI of the right shoulder has not been established in the records submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the right shoulder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the right shoulder (73223).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 and half leg appliances rendered on July 14, 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 for E0675 will be denied as not 
reasonable and necessary.   
 
We looked at the file and Medicare rules. The services at issue are a PCD described by code E0675. These 
services are denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have 
to pay for the pneumatic compression device (PCD) billed with code E0675 and half leg appliances rendered 
on July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81243 billed for date of service February 16, 
2022. 
 
You asked the Plan to pay for procedure code 81243. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81243 is bundled into payment for code 81329.  
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 81243 
is a column II code to column I code 81329. 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 81243 billed for date of service February 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standby service (99360) provided on August 8, 2022. 
 
You asked the Plan to pay for the physician service. You say that the surgeon believed that monitoring services 
were needed at the time of the procedure. You also say that the documentation provided supports this. The Plan 
denied your request. The Plan says standby services are not payable to physicians. 
 
The Plan must follow Medicare rules. Medicare rules say that standby services are not payable to physicians. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician service have not been met. Therefore, we decided that the Plan does not have to pay 
for the standby service (99360) provided on August 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that every provider feels you can participate effectively 
in a patient rehabilitation program to enable you to be able to go home and finish up with home health of 
needed. The Plan denied your request. The Plan says the records do not show that you have complex 
rehabilitation needs requiring frequent evaluation by a rehabilitation doctor. 
 
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 there is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.