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 on January 24, 2022, to 
January 26, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 secondary diagnosis code I21.A1, described as 
myocardial infarction due to demand ischemia, myocardial infarction secondary to ischemic imbalance. We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that documentation does not support the billed code. Our physician 
reviewer found that the enrollee is an 87-year-old male who presented to the hospital with peri-umbilical 
abdominal pain and was found to have a urinary tract infection. He was started on antibiotics and admitted. 
Workup revealed a mildly elevated troponin most likely related to strain, not ischemia. There was insufficient 
overall evidence for myocardial infarction type 2 in the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 24, 2022, to January 26, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a trans rectal ultrasound provided on May 24, 2022. 
 
You asked the Plan to pay for the trans rectal ultrasound. You say that the claim should be paid as billed. The 
Plan denied your request. The Plan says current procedural terminology (CPT) code 76872 remains not 
supported. 
 
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 76872 is ultrasound by transrectal approach. 
 
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 trans rectal ultrasound. Our reviewer says that the 
documentation does not support procedure code 76872. Our reviewer found the operative report does not 
contain a description of a transrectal ultrasound in which the pelvis is visualized. It cannot be verified that this procedure was performed. 
 
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 trans rectal ultrasound have not been met. Therefore, we decided that the 
Plan does not have to pay for a trans rectal ultrasound provided on May 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy 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 inpatient 
rehabilitation facility. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HBA1/HBA2 (alpha globin 1 and alpha globin 2) gene 
analysis (81257). 
 
You asked the Plan to pre-approve HBA1/HBA2 gene analysis. You say that this test is necessary and would 
benefit the enrollee. The Plan denied your request. The Plan says this gene is not medically necessary in this 
case and is not approved for the requested use. 
 
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 HBA1/HBA2 gene analysis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation does not sufficiently support that this testing 
will improve outcomes and/or change physician care and treatment of 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 HBA1/HBA2 gene analysis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve HBA1/HBA2 (alpha globin 1 and alpha globin 2) gene analysis (81257).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a phrenic nerve stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed alternative 
treatment options. The Plan denied your request. The Plan says the enrollee does not have respiratory 
insufficiency. The Plan follows Medicare rules. Medicare rules say that phrenic nerve stimulators are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has complex sleep apnea with the majority of events being central. The records 
indicate a history of intolerance of a continuous positive airway pressure (CPAP) device. There is insufficient 
evidence of the safety and efficacy of this device in the treatment of central sleep apnea. Therefore, the request 
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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a phrenic nerve stimulator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided to you on January 31, 
2022. 
 
You asked the Plan to pay for the services. You say that the services were denied in error. The Plan denied your 
request. The Plan says this provider 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 a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
psychotherapy services provided to you on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the laboratory services. You say that the enrollee is traveling out of country 
and needs monthly labs drawn. The Plan denied your request. The Plan says the records do not indicate that the 
services are urgent or emergent. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 laboratory services. Our reviewer says that the records do not indicate 
that the requested services are medically necessary. Our physician reviewer found the record does not indicate 
that the requested service is emergent in nature or that the need for the testing was unforeseeable at the time. 
 
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 laboratory services have not been met.  
 
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 the laboratory services. Therefore, we decided that the 
Plan does not have to pre-approve laboratory services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the injection services, billed with code J3032, for date of service 
February 25, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medication was not supplied by the 
enrollee's pharmacy. The Plan denied your request. The Plan says that the service was paid in error. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. In this case, the Plan did not provide any documentation to show that the 
drug at issue was dispensed by a pharmacy and brought to the office for administration. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request.  Therefore, we decided that the Plan has to pay for the injection services, billed with code J3032, for 
date of service February 25, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you fully for eyeglasses provided in India on  
December 6, 2022. 
 
You asked the Plan to reimburse you fully for the eyeglasses. You say that you lost your eyeglasses while in 
India and you had a difficultly driving. You say that your prescription changed, and the eyeglasses were a 
necessary emergency. The Plan denied your request. The Plan says the Plan has reimbursed you the full 
eyewear benefit amount of $100 and you are financially responsible for the balance. Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services up to $100 every year for non-Medicare covered prescription eyewear. You are 
responsible for any amount above the eyewear coverage limit.  
 
We looked at the file and the Plan's rules. The file shows that the Plan has reimbursed you the full eyewear 
benefit amount of $100 and you are financially responsible for the balance. Therefore, we decided that the Plan 
does not have to reimburse you fully for eyeglasses provided in India on December 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure coded as 22612 and 22840. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that you are requesting reconsideration 
as the doctor feels that the requested procedure is medically necessary to be performed. The Plan denied your 
request. The Plan says this device as a stand-alone procedure has not been shown to be safe and effective in 
long term studies. 
 
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 Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Minuteman procedure is experimental for back pain. 
 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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure coded as 22612 and 22840.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block, with imaging and sedation. 
 
You asked the Plan to pre-approve the injection. You say that before you can have your implant inserted, you 
need this shot along with another one to see if it can work for you. The Plan denied your request. The Plan says 
the requested nerve block 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 the injection. Our reviewer says that the 
requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested service is considered experimental and investigational. The reviewer 
found that it is the subject of ongoing clinical trials. Therefore, the reviewer found that the requested nerve 
block is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block, with imaging and sedation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 20, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service November 
14, 2022. 
 You asked the Plan to pay for procedure code 97110. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 97110 is bundled into payment for code 64493. 
 
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 97110 
is a column II code to column I code 64493. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 97110 billed for date of service November 14, 
2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that it is recommended to follow Evenity with Prolia for 
best continued bone health. The Plan denied your request. The Plan says that the enrollee has not tried and 
failed the preferred drug. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have been met. Our physician reviewer found the record indicates that the enrollee has 
completed a course of Evenity. The record includes a physician statement that sufficiently establishes that the 
plan's preferred alternatives would have an adverse effect upon the enrollee. Therefore, the reviewer found that 
the step therapy criteria have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia (J0897).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD test panel provided April 15, 2022. 
 
You asked the Plan to pay for the AVISE CTD test panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the AVISE CTD test panel is considered experimental and 
investigational. 
 
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 AVISE CTD test panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the AVISE CTD test panel is considered experimental and investigational, as it is 
unproven to alter disease prognosis or treatment outcomes and has not been proven to be superior to alternative 
tests and measures of disease activity. The review has determined that the items/services at issue in this case 
are not medically reasonable or 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 AVISE CTD test panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the AVISE CTD test panel provided April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99490) provided on November 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not 
support the billed code. 
 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 99490 is "Chronic care management services with the 
following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or 
until the death of the patient, chronic conditions that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, 
revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health 
care professional, per calendar month". 
 
We find that CPT code 99490 is not supported in the medical record. Specifically, the original records do not 
include the time spent providing the service in question. Additionally, the records provided are for date of 
service November 8, 2022. The provided documentation does not contain medical records for the date of 
service in question. Based on this information, we decided that Medicare rules for coverage of the services 
have not been met. Therefore, we decided that the Plan does not have to pay for the services (99490) provided 
on November 30, 2022.