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

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that these were separate procedures and should 
not be bundled. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment 
for code 70551. 
 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 70544 is a column II code to column I code 70551. The code at issue 
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 
70544 billed for date of service July 13, 2022.
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 the enrollee will fail at a lower level of 
care secondary to their prolonged medical history, frequency of complications, and fragility in their current 
state. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for admission to an 
LTACH. 
 
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 the enrollee appears to be improving with the current treatment regimen and should 
only require short-term additional acute care services that can safely be administered at the current facility. 
Transfer to the LTACH would not be clinically advantageous at this time and completion of treatment at the 
current facility is recommended. 
 
 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on February 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testosterone injection provided on August 22, 2022. 
 
You asked the Plan to pay for the testosterone injection. You say that the testosterone injection was medically 
necessary. The Plan denied your request. The Plan says the testosterone injection was 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 pay for the testosterone injection. Our reviewer says 
that the requested testosterone injection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 73-year-old with diagnosed hypogonadism and anemia with low 
vitamin B12 and low testosterone levels who complained of fatigue. The testosterone level was 275 on  
June 14, 2021, 391 on December 14, 2021, and 236 on June 27, 2022. A testosterone injection was provided on 
August 22, 2022 to help with fatigue.  However, the current literature (Testosterone Treatment in Adult Men With Age-Related Low Testosterone: A 
Clinical Guideline From the American College of Physicians. Ann Intern Med 2020; 172:126-133) does not 
support testosterone injections for age-related decline in testosterone such as the case of this enrollee. A review 
of the literature summarizes that testosterone should not be initiated to improve energy, and the long-term 
safety of this practice in those older than 65 is unknown or unclear. Therefore, without sufficient support made 
for this request for the testosterone injection, it will be considered 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 testosterone injection have not been met. Therefore, we decided that the 
Plan does not have to pay for a testosterone injection provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hyaluronan or derivative, durolane, for intra-articular 
injection, 1 mg (J7318). 
 
You asked the Plan to pre-approve an injection. You say that the injection is medically necessary. 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 an injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no formal diagnostic imaging studies provided for review to corroborate osteoarthritis 
in the right knee. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested injection in this clinical setting in the absence of confirmed osteoarthritis. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the enrollee does not meet the LCD criteria for approval of the injection. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hyaluronan or derivative, durolane, for intra-articular injection, 1 mg (J7318).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of cervical spine 
without contrast (72141). 
 
You asked the Plan to pre-approve an MRI of cervical spine without contrast. You say that you want the Plan 
to approve the service. 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 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 cervical spine without 
contrast. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has documented cervical degenerative disc disease by MRI in December 2020. Per the office note 
dated January 17, 2023, the enrollee is asymptomatic and stable at present. The enrollee has left shoulder pain, 
and it appears that the physician is attempting to order an MRI of the shoulder. This is the intention per the 
office note dated January 17, 2023. Based on the records, it is likely that this request for the cervical spine MRI 
is an order entry error. 
 
   
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 cervical spine without contrast have not been met. Therefore, we 
decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of cervical spine 
without contrast (72141).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 29, 2022, to 
April 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was resubmitted with 
the correct date. 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 looked at the file and the Medicare rules. The admission date on the claim was billed as December 29, 
2021. We find that the admission date reported on the claim at issue was not billed with 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 
March 29, 2022, to April 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on January 10, 2022. 
 
You asked the Plan to pay for an electrocardiogram (ECG). You say that you would like this reprocessed with 
the supporting records that you submitted The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an electrocardiogram 
(ECG) provided on January 10, 2022.
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 the LTACH is the only appropriate level 
of care for the enrollee. You say that the LTACH will be able to attend to all of the enrollee's ongoing needs in 
order to have a successful recovery. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have not been met. 
 
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 the enrollee appears to be improving with the current treatment regimen and should 
only require short-term additional acute care services that can safely be administered at the current facility. 
Transfer to the LTACH would not be clinically advantageous at this time and completion of treatment at the 
current facility is recommended. 
 
 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.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for services provided on 
September 28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was processed closer to 99283. The 
Plan denied your request. The Plan says code 99284 is not substantiated by the clinical documentation. 
 
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 99284 is an emergency department visit of high severity, 
and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an 
immediate significant threat to life or physiologic function. 
 
We find that CPT code 99284 is not supported in the medical record. The records show that the enrollee 
presented to the emergency room with a possible fishbone lodged in her upper throat. The enrollee was able to 
swallow, drink water, and eat small bites. The enrollee stated her symptoms resolved after some time in the 
emergency room. The records do not show that the enrollees presenting problems were of high severity. 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 99284 billed for services provided 
on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 Sensor. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the member does not use insulin with at least three daily 
injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 Sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the test results were medically necessary. The 
Plan denied your request. The Plan says the records do not support the coding. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested. 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 
G0482 billed for date of service October 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous immunoglobulin (IVIG) (Gammagard) 
(J1569). 
 
You asked the Plan to pre-approve IVIG. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested use of IVIG is not approved by the FDA for the enrollee's 
condition. 
 
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 IVIG. Our reviewer says that the 
requested IVIG is not medically necessary. Our physician reviewer found the provided documentation is not 
sufficient to establish the diagnosis of autoimmune hemolytic anemia as hemolysis has not been demonstrated 
in the setting of receiving myelosuppressive chemotherapy. The reviewer found that the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested IVIG is 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 IVIG have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intravenous immunoglobulin (IVIG) (Gammagard) (J1569).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent 
leadless pacemaker (33724). 
 
You asked the Plan to pre-approve the outpatient service. You say that the enrollee's health is on the line 
without the pacemaker. The Plan denied your request. The Plan says the requested service is not being provided 
in conjunction with a CED (Coverage with Evidence Development) study. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when 
furnished outside of a Centers for Medicare and Medicaid Services (CMS) approved CED study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient service have not been met. Therefore, we decided that the Plan does not have to pre-
approve transcatheter insertion or replacement of permanent leadless pacemaker (33724).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF admission is not medically necessary, reasonable, and appropriate 
for the enrollee's condition. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable loop recorder (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that you are providing clinical 
relevance medical information to justify the placement of a loop recorder that would be appropriate and 
covered by the medical insurance program. The Plan denied your request. The Plan says the records do not 
support medical necessity of the requested service. 
 
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 implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation provided to suggest a history of recurrent, unexplained syncope, cryptogenic stroke or any other apparent indication for an implantable loop recorder. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an implantable 
loop recorder in this enrollees clinical management. 
 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantable loop recorder (33285).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 26, 
2022. 
 You asked the Plan to pay for procedure code 76642. You say that the denied service was coded correctly. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service October 26, 2022.