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

 
We decided that the Plan does not have to pay for inpatient hospital services provided from October 20, 2020, 
to October 22, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that this claim should be paid. The Plan 
denied your request. The Plan says the principal diagnosis billed on the claim is not appropriate.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate principal diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code J10.1 (influenza due to 
other identified influenza virus with other respiratory manifestations). 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. Our reviewer says that a principal diagnosis of 
J10.1 (influenza due to other identified influenza virus with other respiratory manifestations) is not the 
appropriate principal diagnosis for this hospital admission. Our physician reviewer found that the 
documentation supported an admission for hypertensive systolic heart failure exacerbation. Although the 
provider noted "Patient was admitted with chronic obstructive pulmonary disease (COPD) extubation influenza 
type B and systolic congestive heart failure exacerbation" in the discharge summary, per coding guidelines, the 
principal diagnosis would be the condition which led to the hospital inpatient admission. In this case, provider 
documentation indicated the patient was being admitted to inpatient care for a hypertensive systolic heart 
failure exacerbation.  Diagnosis code I11.0 (Hypertensive heart disease with heart failure) was sequenced as the 
principal diagnosis and code J10.1 was sequenced as a secondary diagnosis consistent with the documentation 
that was received.  
 
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 from October 20, 2020, to October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spirometer. 
 
You asked the Plan to pre-approve a spirometer. You say that a spirometer is medically necessary. The Plan 
denied your request. The Plan says a spirometer is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  A spirometer does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a spirometer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Bevacizumab. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our physician reviewer found 
that in this case, the record indicates that the enrollee has macular edema in the setting of retinal vein occlusion.  
The requested medication is a new start. The Plan requires a trial of bevacizumab before they will approve the 
requested drug. The provided records do not indicate that the enrollee has tried and failed the plan's preferred 
step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an 
adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that you would like reconsideration because the 
requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
step therapy exception criteria. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives, 
Infed (iron dextran) and Venofer (iron sucrose). Our physician reviewer found the record does not indicate that 
the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement (36215) and angiography 
services (75710) provided on October 7, 2021. 
 
You asked the Plan to pay for the selective catheter placement and angiography services. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 
codes 36215 and 75710 are included in 36902. 
 
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 36215 is selective catheter placement, arterial system; 
each first order thoracic or brachiocephalic branch, within a vascular family. 
 
The CPT Code Manual definition of code 75710 is angiography, extremity, unilateral, radiological supervision 
and interpretation. 
 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 selective catheter placement and angiography services. 
Our reviewer says that CPT codes 36215 and 75710 do not meet criteria for billing or reimbursement 
consideration. Our reviewer found the operative report describes selective catheter was advanced from the 
circuit into the arterial inflow, however, this procedure is separately reported when there is a suspected inflow 
problem separate from from the peripheral dialysis segment. In this case, documentation does not support a 
suspected inflow problem. 
 
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 selective catheter placement and angiography services have not been met. 
Therefore, we decided that the Plan does not have to pay for selective catheter placement (36215) and 
angiography services (75710) provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5261, V5257). 
 
You asked the Plan to pre-approve hearing aids. You say that these hearing aids are necessary, and you cannot 
afford them without insurance. The Plan denied your request. The Plan says these services are not covered by 
Medicare or your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids 
(V5261, V5257).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83540, 83550, 84100 
and 84460) provided on September 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contractual agreement in place which indicates that the CPT codes billed are included in the dialysis 
rate. The Plan denied your request. The Plan says all laboratory services furnished to individuals for the 
treatment ofESRD are included in the ESRD PPS as Part B services and are not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (82310, 82728, 83540, 83550, 84100 and 84460) provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) and injections (20550, 20611) 
provided on October 18, 2021. 
 
You asked the Plan to pay for an office visit with injections. You say that the Plan has paid for the same 
services for another date of service and should match their payment for the date and services at issue in this 
case. The Plan denied your request. The Plan says rules for payment have not been met because the provider at 
issue has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit (99204) and injections (20550, 20611) provided on October 18, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency medicine services provided on June 13, 2019. 
 
You asked the Plan to pay for the emergency medicine services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was not filed 
timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency medicine services was not filed until November 20, 2020. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the emergency medicine services provided on June 
13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services (97814, 97813). 
 
You asked the Plan to pre-approve acupuncture. You say that these services are necessary. The Plan denied 
your request. The Plan says there is no documentation to support that the enrollee has chronic low back pain as 
defined by Medicare standards. Therefore, the request for acupuncture is not medically necessary in this case. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the medical records note that the enrollee has been 
experiencing intermittent and increasing neck, lower back and leg pain over the course of one week. Chronic low back pain is defined by Medicare as lasting 12 or more weeks, having no identifiable systemic 
cause, and is not associated with either pregnancy or surgery. Therefore, we decided that the Plan does not have 
to pre-approve acupuncture services (97814, 97813).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services provided on June 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin 
injections provided on June 17, 2021. 
 
You asked the Plan to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic 
sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve 
Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections provided. The Plan denied 
your request. The Plan says Medicare does not cover Prolotherapy. Prolotherapy is believed to stimulate the 
bodys ability to heal itself by injecting a natural substance that acts as an irritant and stimulates regenerative 
processes. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered, 
which is like acupuncture. The Transcutaneous Electrical Nerve Stimulation (TENS) device, including 
supplies, for neuromuscular reconditioning is not a Medicare covered benefit. Multivitamin injections 
(compounded Nutria), prolotherapy/acupuncture\, into the nerve and musculoskeletal structures are not a 
Medicare covered benefit Pneumatic / vasopneumatic devices can be covered only for the treatment of chronic 
venous insufficiency with venous stasis ulcers, and refractory lymphedema. Examinations before, during and 
after treatment are likewise non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say the use of vasopneumatic devices may be considered 
reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema or 
lymphedema. The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using 
a compounded drug, not otherwise classified (NOC) code. Medicare rules say claims for Prolotherapy must not 
be reported with the trigger point codes or other injection codes 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), 
vasopneumatic device, Prolotherapy and vitamin injections provided have not been met. Therefore, we decided 
that the Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, 
kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical 
Nerve Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections provided on 
June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical collar (L0180) provided on June 24, 2021. 
 
You asked the Plan to pay for a cervical collar. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the available medical records do not discuss the item at issue. Therefore, we decided 
that the Plan does not have to pay for a cervical collar (L0180) provided on June 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent Pen (C9399). 
 
You asked the Plan to pre-approve Praluent Pen. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by Medicare Part B. The Plan also says that this drug is self-administered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent Pen (C9399).  
 
Benefits for Praluent Pen may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D4263), guided tissue 
regeneration (D4266) and free soft tissue graft procedures (D4277). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement grafts (D4263), guided tissue regeneration (D4266) and free soft tissue graft procedures (D4277).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm (J0172). 
 
You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use of Aduhelm is not supported. 
 
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 Aduhelm. Our reviewer says that the 
requested use of Aduhelm is not supported. Our physician reviewer found the brain imaging included in the 
records suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the 
enrollee's symptoms. It has not been demonstrated that Aduhelm is at least as beneficial as existing medically 
appropriate alternatives for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm (J0172).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
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 that the patient is a 75-year-old male who was admitted to the acute care hospital for 
acute on chronic heart failure requiring aggressive diuresis and complicated by acute on chronic kidney failure 
and chronic obstructive pulmonary disease. Recent notes describe the patient as currently having worsening 
foot cellulitis, worsening anemia, and unstable kidney function. The patient appears to be somewhat unstable 
and requires short-term additional acute care services that can be safely completed at the current facility until 
more stable. The patient does not require services at the LTACH that are not already available at the current 
facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Transfer to LTACH will be considered not medically necessary at this time as it would 
not be clinically advantageous. Transfer may be considered when treatment has completed and the patient is 
more stable. 
 
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 long term acute care hospital (LTACH) services.