Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided to the enrollee on July 8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this claim contains code pairs found to be unbundled, according to the guidelines. 
 
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 99223 
is a column II code to column I code 31629. 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 initial hospital care provided to the enrollee on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) cardiologist. 
 
You asked the Plan to pre-approve an office visit. You say that on the Plan's member website, the 
recommended in-network physician is not listed as doing cardiac work up or cardiac surgeries, and the other 
physician is not accepting new patients. The Plan denied your request. The Plan says the services have been 
requested out-of-network and the plan has recommended in-network physicians that are accepting new patients. 
 
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 
an office visit to be provided by an out-of-network (OON) cardiologist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. 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 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 provided on April 2, 2021.
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 you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not covered for the enrollee. 
 
 
 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 reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has cystoid macular degeneration/edema of the left eye. Based on the medical 
records provided and the Medicare-approved major drug compendia there is no documentation that the 
requested treatment with Eylea meets Medicare criteria for coverage. Provided records do not document a 
medically-accepted indication for use of Eylea. Cystoid macular degeneration/edema is not a medically-
accepted indication for use of Eylea. Therefore, the enrollee does not meet criteria for the requested drug. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you can't use one leg and you are very weak from 
surgery. You say that you need more time to recover. The Plan denied your request. The Plan says that you do 
not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation states that you have multiple comorbidities that would benefit from close medical 
supervision on an inpatient basis focused on rehabilitation. Evaluating therapists recommend intense 
rehabilitation and require multiple therapy disciplines, thus it is reasonable to expect you will significantly 
benefit and participate in an intensive rehabilitation program. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 21, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
 
 
 
 
 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 27301 
is a column II code to column I code 27340. 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 surgical services provided to the enrollee on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dialysis services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services can be received in-network. 
 
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 
dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99053) provided October 12, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (99053) provided October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller for an approved power 
wheelchair, with related electronic connections and harness. 
 
You asked the Plan to pre-approve the expandable controller and related components. You say that it is felt that 
the items should be approved as requested. The Plan denied your request. The Plan says all requested items 
were approved except for the expandable controller which is not deemed 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 the expandable controller and related 
components. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the requested electrical accessories are not medically necessary as 
the member does have use of the upper extremity and can operate and control the power options using the 
switches that are included with those options. 
 
 
 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 expandable controller and related components have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller for an approved power 
wheelchair, with related electronic connections and harness.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the thorax (71250). 
 
You asked the Plan to pre-approve a CT of the thorax. You say that the records provided support the need for a 
repeat CT scan. The Plan denied your request. The Plan says this request exceeds the need and is not medically 
necessary according to the Medicare rules because there is no evidence of new or changing symptoms that a 
CT chest would identify nor a need to change her current treatment plan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT of the thorax. Our reviewer says 
that a CT of the thorax is not reasonable and necessary. Our physician reviewer found there is no 
documentation that the enrollee's provider needs the study to change the enrollee's treatment after they tested 
positive for COVID- 19, and the enrollee's symptoms are getting much worse. Our reviewer also found that 
there is no evidence that the enrollee tested positive for COVID-19 and had gotten better, but still has problems 
that affect her function and/or low oxygen levels. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT of the thorax have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the thorax (71250).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. 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 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 provided on March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device (PCD) 
coded as E0651. 
 
You asked the Plan to pre-approve the E0651 PCD. You say that you feel that use of the PCD would be much 
more effective than your current treatment and would not be as difficult. You believe this is a medical 
necessity. The Plan denied your request. The Plan says because conservative treatment has led to improvement 
in your symptoms, there is no need for a PCD at this time. 
 
The Plan follows Medicare rules. Medicare rules say that PCDs are not considered reasonable and necessary 
when there is marked improvement in symptoms after a four-week trial of conservative management. 
 
 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 E0651 PCD. Our reviewer says that 
the documentation does not support the medical need of a PCD in this case. Our physician reviewer found 
based on the latest provided records, there is documentation that the enrollee has had improvement in his lower 
extremity swelling with conservative therapy. As of 03/11/2022, records show a total reduction in right lower 
extremity swelling by 7.5 cm and by 9.7cm in the left lower extremity. As stated in the LCD: "At the end of the 
four-week trial, if there has been improvement, then reimbursement for a PCD is not justified." 
 
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 E0651 PCD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a segmented pneumatic compression device (PCD) coded as E0651.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) interpretation and report 
(93010) provided on November 6, 2021. 
 
You asked the Plan to pay for the ECG interpretation and report. You say that this service was billed 
appropriately and was separate from the primary procedure. The Plan denied your request. The Plan says a 
National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 92950 and 
93010. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this claim to bypass this PTP code edit. This service was 
not billed appropriately by Medicare coding regulations. 
 
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 93010 
is a column II code to column I code 92950. 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 electrocardiogram (ECG) interpretation and report (93010) 
provided on November 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence testing (NGS) testing panel 
provided on February 8, 2022. 
 
You asked the Plan to pay for the next generation sequence testing (NGS) testing panel. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include the FANCC gene are non-
covered.  
 
 We looked at the file and Medicare rules. Review of the file shows that the NGS testing provided included 
testing for the FANCC gene. This means the entire panel is not covered. Based on this information, we decided 
that Medicare rules for coverage of the next generation sequence testing (NGS) testing panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the next generation sequence testing (NGS) 
testing panel provided on February 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. The Plan denied your request. The Plan says the request for an 
echocardiogram without new clinical signs or symptoms is not medically necessary under Medicare, as it 
exceeds the member's medical need and is not medically appropriate in this setting. 
 
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 a TTE. Our reviewer says that the 
requested TTE is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee has no new cardiac symptoms or complications, which would indicate a change in their cardiac 
condition. The records indicate the enrollee was seen for an annual follow up visit with no new complaints. Our 
reviewer also found that there is no clinical rationale for the requested TTE. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE) (93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from January 7, 2021, to 
January 12, 2021, as billed with Diagnosis Related Group (DRG) 872. 
 
 You asked the Plan to pay for inpatient care billed with DRG 872. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 872 is not 
appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 690 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 872. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the enrollee presented to the facility with hip 
pain following a fall. The enrollee had a past medical history of congestive heart failure, diabetes, gout, 
hypertension, and chronic kidney disease. Initial vital signs in the emergency room indicated a temperature of 
97.8 degrees Fahrenheit, a blood pressure of 118/82, a heart rate of 110, a respiratory rate of 26, and an oxygen 
saturation (SpO2) of 95% on room air. Laboratory data also revealed a white blood cell count of 16.53. The 
enrollee was admitted and diagnosed with a urinary tract infection. The enrollee had a Glasgow Coma scale 
Score of 15, and the history and physical indicated that the enrollee was in no apparent distress. Additional 
laboratory data revealed a platelet count of 267 and a total bilirubin of 0.6. While the creatinine was elevated at 
1.6 and increased to 2.23 on January 9, 2021, the enrollee had chronic kidney disease and no baseline 
creatinine was provided. There was no clinical or laboratory evidence of sepsis. The review has determined that 
the medical records did not support the billing of sepsis, unspecified organism (A41.9). 
 
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 872 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from January 7, 2021, to January 12, 
2021, as billed with Diagnosis Related Group (DRG) 872.