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

 
We decided that the Plan does not have to pre-approve treatment with Keytruda as part of an anticancer 
regimen. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-label, 
not medically accepted use. 
 
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 is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Keytruda is not FDA-approved for the enrollees diagnosis. Furthermore, the use is not 
supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved 
medical journal. 
 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 treatment with Keytruda as part of an anticancer regimen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid check provided on August 30, 2022. 
 
You asked the Plan to pay for the hearing aid check. You say that the nearest network audiologist was 50 miles 
away. You say this was a follow-up visit recommended by your physician and this should be covered. The Plan 
denied your request. The Plan says the provider was out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by a network provider. 
 
We looked at the file and and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid check have not been met. Therefore, we decided that the Plan does not have to pay 
for the hearing aid check provided on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service April 20, 
2022. 
 
You asked the Plan to pay for the billed code. 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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. 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 procedure code G0483 billed for date of service April 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 23, 2022 to 
June 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. 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 May 23, 2022 to June 
21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 24, 2022, to 
January 27, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported appropriately and are supported as billed. The Plan denied your request. 
The Plan says the DRG submitted on this claim is not supported in the medical records. 
 
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 sepsis due to Escherichia Coli (A41.51). We asked 
our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally 
billed. Our reviewer says that this diagnosis code is not supported in the medical records. Our physician 
reviewer found the documentation does not indicate that the diagnostic work-up and treatment ordered by the 
treating medical providers supported a diagnosis code A41.51 (Sepsis due to Escherichia coli). There was no 
evidence of life-threatening organ dysfunction due to dysregulated host response to an infection or persistent 
hemodynamic instability. The documentation does not consistently and completely support the assigned 
principal diagnosis code with DRG. The replacement of DRG is upheld as this is supported by the medical 
documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 24, 2022, to January 27, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Anesthesia for intraoral procedures, including biopsy; not otherwise 
specified (00170) provided August 2, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this was sent for a coding review and your 
codes determined that coding is correct. Please reprocess your anesthesia claim based on the attached 
anesthesia records. The Plan denied your request. The Plan says that the appealed services do not fall under the 
covered services. 
 
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 Evidence of Coverage specifically says that anesthesia can be covered as 
needed with covered procedures. The records show that the procedure completed was surgical extractions. 
There is also coverage for surgical extractions with unlimited procedure codes. However, the Plan has not 
provided any documentation specifying that the surgical extractions procedure was covered by the Plan or 
denied by the Plan. Without knowing whether the associated extractions were covered and necessary, we 
cannot determine if whether the anesthesia should also be covered. Therefore, we decided that the Plan has to 
pay for Anesthesia for intraoral procedures, including biopsy; not otherwise specified (00170) provided August 
2, 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 procedure code 87634 billed for date of service January 6, 
2022. 
 You asked the Plan to pay for procedure code 87634. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 87634 is bundled into payment for code 87632. 
 
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 87634 is a column II code to column I code 87632. 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 87634 
billed for date of service January 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97010 and 97026 billed for date of service 
November 5, 2021. 
 
You asked the Plan to pay for procedure codes 97010 and 97026. The Plan denied your request. The Plan says 
procedure code 97010 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. We also find that the infrared therapy services have not been 
shown to be reasonable and necessary in this case. 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 procedure codes 
97010 and 97026 billed for date of service November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37211 billed for date of service July 18, 
2022. 
 You asked the Plan to pay for procedure code 37211. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 37211 is bundled into 
payment for code 37184. 
 
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 37211 
is a column II code to column I code 37184. 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 37211 billed for date of service July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on August 18, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that follow-up visits during the postoperative period of the 
surgery that are related to recovery from the surgery are included in the global surgical package.  
 
We looked at the file and Medicare rules. Procedure code 99214 was related to and billed within the 90 day 
global surgical period for major procedure 36832 billed for May 20, 2022. Payment for code 99214 is included 
in the global surgical package. Therefore, we decided that the Plan does not have to pay for the office visit 
rendered on August 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee's previous sacroiliac injection 
provided 80% relief. The Plan denied your request. The Plan says that the requested service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that diagnostic and therapeutic injections of the SI joint 
would not likely be performed unless conservative therapy and noninvasive treatments have failed. 
 
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 injection. Our reviewer says that the 
requested sacroiliac joint injection is medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollee takes Tylenol along with a home exercise program. The reviewer 
found that a prior SI joint injection was performed which provided 90% pain relief for 3 months. Therefore, the 
reviewer found that the injection 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 the injection have been met. Therefore, we decided that the Plan has to pre-
approve a sacroiliac joint injection (27096).  
 
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 code 99442 billed for date of service November 23, 2021. 
 
You asked the Plan to pay for code 99442. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the rules for payment of this code have not been met. 
 
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 99442 is telephone evaluation and management service 
provided by a physician to an established patient, parent, or guardian not originating from a related evaluation 
and management (E/M) service provided within the previous seven days nor leading to an E/M service or 
procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, records show that the same 
provider billed for another E/M service on November 16, 2021 (which is within 7 days of the billed code 
99442). The definition of code 99442 states that this code only applies to services NOT originating from a 
related E/M service within the previous seven days. Based on this information, we decided that Medicare rules for coverage of code 99442 have not been met. Therefore, we decided that the Plan does not have to pay for 
code 99442 billed for date of service November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
the request 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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee has left hemiparesis and 3/5 strength 
in the right upper extremity. The enrollee has adequate strength in the right upper extremity to manage standard 
power switches on a power wheelchair. 
 
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 expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service June 5, 2022. 
 
You asked the Plan to pay for the billed code. The Plan denied your request. The Plan says the documentation 
does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 93010 is not supported in the medical record. Specifically, the records do not show that 
the provider at issue provided the service, or was a supervising provider. Based on this information, we decided 
that Medicare rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 93010 billed for date of service June 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute/knee scooter. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a Medicare-covered benefit. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record recommends heel walking in a hard shoe. The documentation does not support medical 
necessity. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crutch substitute/knee scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving but still requiring short-term additional 
acute care hospital services including weaning attempts that can safely be provided at the current facility until 
more appropriate for transfer. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary at this time as it would not 
be clinically advantageous. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.