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

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from September 4, 
2022, to September 7, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that care could have been provided at a lower level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from September 4, 2022, to September 7, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
29, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 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 76641 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 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0652) and 
segmental pneumatic appliances (E0667, E0656) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device and accessories. You say that the in-
network providers do not provide the pump you need. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 the pneumatic compression device (E0652) and segmental pneumatic appliances (E0667, E0656) to be 
provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that this claim was not a duplicate, so it should 
be reprocessed. The Plan denied your request. The Plan says procedure code 99053 is considered bundled and 
not separately payable. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service June 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 1, 2022 to July 
30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided additional 
documentation to support payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 1, 2022 to July 30, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71046) provided on August 20, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 71046 is not supported in the medical record. Specifically, diagnosis code T46.2X5A is 
not a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of 
the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for 
radiology services (71046) provided on August 20, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 0089U. We decided that the Plan does not have to pay 
for procedure code 81345.  
 
You asked the Plan to pay for laboratory services (0089U, 81345) provided on October 20, 2021. You say that 
these services were necessary and should be paid. The Plan says that these services are denied. 
 
We decided that the Plan has to pay for procedure code 0089U.  
 
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 did not provide a reason for denial before the required 
timeframe. Medical records were included in the case file. Because the Plan has not provided a supported 
argument for denial, we decided that the Plan has to pay for procedure code 0089U.  
 
We also decided that the Plan does not have to pay for procedure code 81345. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, code 81345 was billed with the GZ modifier. 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 81345. 
 
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: Favorable

 
We decided that the Plan has to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the enrollee meets criteria for proton 
beam radiotherapy. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
proton beam therapy. 
 
The Plan follows Medicare rules. Medicare rules state that proton beam therapy may be covered for certain 
conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says 
that the enrollee meets criteria for the requested proton beam therapy. Our physician reviewer found for this 
enrollee, the cardiac and lung exposures are markedly reduced with proton therapy. the photon (non-proton) 
plan for this enrollee greatly exceeds the protocol for heart constraints, and though both the proton and 
intensity-modulated radiation therapy (IMRT) plan are not within the Radiotherapy Comparative (RADCOMP) 
criteria, the proton plan is markedly better. The proton therapy plan reduces the ipsilateral lung mean dose as 
well. Thus, the requested proton therapy would not be investigational. It is possible that there would be a 
benefit in this enrollee even if a better optimized IMRT plan were run to better prioritize lung sparing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have been met. Therefore, we decided that the Plan has to 
pre-approve proton beam therapy.  
 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: Favorable

 
We decided that the Plan has to pay for angiography (procedure code 75726 and 75774) provided to the 
enrollee on September 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 codes 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 
the denied codes is: 
 
CPT 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (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 services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation supports coverage 
of the codes in question.  Catheterization and angiographic codes performed prior to vascular embolization are 
separately billable and not included within the embolization code. The catheterization codes have been 
previously approved. Specifically with CPT 75726, this codes for visceral angiography. This has been 
satisfactorily documented in the record. For CPT 75774, this is an add-on code for each additional selective 
angiogram following initial angiography and requires separate positioning of the catheter. There is satisfactory 
documentation that the right colic artery was selected, and angiography performed, and the middle colic artery 
was selectively catheterized, and angiogram 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 been met. Therefore, we decided that the Plan has to pay for 
angiography (procedure code 75726 and 75774) provided to the enrollee on September 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array (Sprint PNS). 
 
You asked the Plan to pre-approve a Sprint PNS. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that payment may be made under the prosthetic device 
benefit for implanted peripheral nerve stimulators. 
 
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 Sprint PNS. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found this is considered an experimental 
procedure at this time and is the subject of ongoing clinical trials. Therefore, the request is considered not 
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 a Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array (Sprint PNS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (98942) provided on May 25, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that every chiropractic claim (those containing CPT 
codes 98940, 98941, or 98942) with a date of service on or after October 1, 2004 is to include the AT modifier 
if active/corrective treatment is being performed. 
 
We looked at the file and Medicare rules. This code was not billed with the required AT modifier. Based on 
this information, we decided that Medicare rules for coverage of the chiropractic services have not been met. 
Therefore, we decided that the Plan does not have to pay for chiropractic services (98942) provided on May 25, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the posterior tibial nerve stimulation (64566) provided from 
September 30, 2022, to October 14, 2022. 
 
You asked the Plan to pay for the PTNS. You say that the services were medically necessary for the enrollee. 
The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for initial therapy must document failed 
standard anticholinergic drug therapy or an intolerance to it. 
 
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 PTNS. Our reviewer says that the PTNS 
was not medically necessary. Our physician reviewer found the provided documentation does not support that 
you have trialed standard anticholinergic drug therapy. Therefore, the reviewer found that the PTNS was not 
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 the PTNS have not been met. Therefore, we decided that the Plan does not have 
to pay for the posterior tibial nerve stimulation (64566) provided from September 30, 2022, to October 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 30, 
2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve arthroscopic biceps tenodesis (CPT 29828). 
 
You asked the Plan to pre-approve arthroscopic biceps tenodesis. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 arthroscopic biceps tenodesis. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is planning to undergo a right shoulder arthroscopic rotator cuff 
repair. The concomitant repair of the biceps tendon has been shown to be an effective treatment with imaging 
evidence of pathology. The magnetic resonance imaging (MRI) was noted to show significant tendinopathy of 
the long-head biceps tendon. Not addressing the biceps pathology during the rotator cuff surgery, could lead to 
continued right shoulder pain and functional limitations. Therefore, the requested arthroscopic biceps tenodesis 
(CPT 29828), 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 arthroscopic biceps tenodesis have been met. Therefore, we decided that the 
Plan has to pre-approve arthroscopic biceps tenodesis (CPT 29828).  
 
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 Prolaris testing (81541) provided on March 1, 2022. 
 
You asked the Plan to pay for Prolaris testing. You say that this test was medically necessary and appropriate. 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of Prolaris testing have 
not been met. Therefore, we decided that the Plan does not have to pay for Prolaris testing (81541) provided on 
March 1, 2022.