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

 
We decided that the Plan does not have to pre-approve Benicar. 
 
You asked the Plan to pre-approve Benicar. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Benicar.  
 
Benefits for Benicar 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88342 and 88341) 
provided on November 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. 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. National Correct Coding 
Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 88189 and 88342. This PTP edit has a 
modifier indicator of 1, modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier 
was not billed with this PTP code edit. Procedure code 88341 denied on the claim for date of service November 
05, 2021, with reason 5031  add on code without appropriate primary procedure. Per the submitted claim, the 
Type I add-on code 88341 was not billed with an appropriate primary that is eligible for payment. Primary code 
88342 denied correctly per the NCCI PTP edit. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code(s): 88342 and 88341) provided on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CGP screening testing (CPT code(s): 81408, 81162, 81292, 
81321, and 81407) provided on October 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. 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. Review of the available 
records presented for an appeal of molecular genetic pathology testing has been completed. After reassessing 
the entire situation, the result is that the initial denial is upheld.  
 As CGP testing is not defined as a targeted panel by MolDX; and is a test not currently satisfactorily described 
by any existing CPT code; to report a Comprehensive Genomic Profile (CGP) testing is not defined as a 
targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to 
report a CGP, service providers should use 1-unit only of CPT code 81479 (used for the entire bundled multi-
test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative 
field for the test; not unbundled to separate codes, or other unlisted code. Medicare says do not list unbundled 
separate codes or another unlisted code on the claim. Therefore, we decided that the Plan does not have to pay 
for CGP screening testing (CPT code(s): 81408, 81162, 81292, 81321, and 81407) provided on October 5, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stereotactic computer-assisted (navigational) 
procedure. 
 
You asked the Plan to pre-approve a stereotactic computer-assisted (navigational) procedure. 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 must follow Medicare rules. Medicare rules say that CPT code 61783 (Stereotactic computer-assisted 
(navigational) procedure; spinal...) shall not be reported for a simple spinal decompression (e.g., CPT codes 
63001-63051). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a stereotactic computer-assisted (navigational) procedure have not been met. Specifically, 
laminectomy (63046) has been approved by the plan. Code 61783 cannot be billed with this type of surgery. 
Therefore, we decided that the Plan does not have to pre-approve a stereotactic computer-assisted 
(navigational) procedure.
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. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Eylea.  
 
Benefits for Eylea 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this service should be covered. The Plan 
denied your request. The Plan says these testings services are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you are no 
longer a threat to self or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued services from April 18, 2022, forward were requested. 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 continued services. Our physician reviewer found that you were admitted to the acute 
inpatient psychiatric hospitalization with major depressive disorder, recurrent, severe without psychotic 
features and alcohol use disorder.   You did not show any abnormal behaviors or any symptoms which would require acute treatment. It did not 
appear medically necessary to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question. It was not expected you would improve in a reasonable period 
of time as you did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You 
did not have dangerousness to self or others and were compliant with your treatment with encouragement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient mental health services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip x-ray (73501) provided on October 6, 2021. 
  You asked the Plan to pay for the hip x-ray (73501). You say that the x-rays were performed on the same day 
and the 1 view x-ray was performed post reduction. You say that this procedure is separately payable, and the 
claim should be reprocessed. The Plan denied your request. The Plan says procedure code 73501 is considered 
inclusive to procedure code 73502. 
 
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 73501 
is a column II code to column I code 73502. 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 the hip x-ray (73501) provided on October 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy with an OON provider. You say that you want to see this 
provider. The Plan denied your request. The Plan says you must use network providers for the services at issue. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The does not enrollee 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
  
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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
urinary tract infection and mental status changes. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that this is medically necessary. 
The Plan denied your request. The Plan says an additional oxygen system is considered a duplicate request and 
will not be covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has stationary oxygen system and portable oxygen system. This equipment 
serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have 
to pre-approve a portable oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Linzess. 
 
You asked the Plan to pre-approve Linzess. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Linzess.  
 Benefits for Linzess 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88364 and 88365) 
provided on March 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. 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. CPT code(s): 88364-TC 
and 88365-TC, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the 
location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an ambulatory surgical center POS 24. Also, the laboratory 
results submitted indicate the specimen was collected on March 23, 2021, and received by the lab on March 24, 
2021. Therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to pay 
for the laboratory services (CPT code(s): 88364 and 88365) provided on March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from February 23, 2020, to 
March 1, 2020, as billed with Diagnosis Related Group (DRG) 193. 
 
You asked the Plan to pay for inpatient care billed with DRG 193. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 193 is not supported as the secondary diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in the 
medical record. The Plan argues that DRG 194 is more appropriate in this case. 
 
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. 
 
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 inpatient care billed with DRG 193. Our 
reviewer says that the secondary diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in 
the medical record. Our physician reviewer found that the enrollee with chronic obstructive pulmonary disease 
(COPD) was admitted and treated for pneumonia and COPD exacerbation. In the emergency department, his 
pulse oximetry was 95% on room air. He started in observation where he was treated with steroids, antibiotics, 
and bronchodilator treatments, then was admitted to the hospital. He was admitted requiring only 1-4 L oxygen 
support via nasal cannula. Based on the provided records, the enrollee did not meet criteria for a secondary 
diagnosis of acute respiratory failure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 193 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from February 23, 2020, to March 1, 
2020, as billed with Diagnosis Related Group (DRG) 193.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 
office visits 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 pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Spravato.  
 
Benefits for Spravato 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from January 11, 2021, 
through January 23, 2021, billed with A41.9. 
 You asked the Plan to pay for the inpatient care as billed. You say that the inpatient care as billed is supported 
in the medical documentation. The Plan denied your request. The Plan says the documentation does not support 
the inpatient care as billed. 
 
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 principal diagnosis code, A41.9, defined as sepsis, 
unspecified organism. 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 care as billed. 
Our reviewer says that the documentation does not support the inpatient care as billed. Our physician reviewer 
found the patient is a 66-year-old male who was admitted and treated in the hospital for cellulitis, iliac crest 
mass, urinary retention. Computed tomography revealed worsening metastatic thyroid cancer mass in pelvis 
with abscess. There was no evidence, however, that there was a life-threatening organ failure related to the 
infection. Sequential Organ Failure Assessment (SOFA) score did not rise 2 or more points. Therefore, there 
was insufficient support made in the documentation to justify the diagnosis of sepsis for this admission.  
 
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 the inpatient hospital care provided from January 11, 2021, through January 23, 2021, billed with A41.9.