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

 
We decided that the Plan does not have to pay for code 99222 billed for date of service September 7, 2022. 
 
You asked the Plan to pay for code 99222. You did not provide a specific argument with your appeal request. 
The Plan denied your request. The Plan says code 99222 is not supported by the medical record because the 
records do not support a comprehensive history or examination. 
 
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 99222 is Initial Hospital Care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. 
 
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 code 99222. Our reviewer says that code 99222 is not supported in the medical record. Our reviewer found a comprehensive examination requires a general 
multisystem examination or a complete examination of a single organ system and medical decision making of 
moderate complexity requires multiple diagnoses or management options, a moderate amount and complexity 
of data reviewed and a moderate risk of complication. Provided records in this case do not document a 
comprehensive history with a chief complaint, an extended history of present illness, a review of all additional 
body systems and a complete past, family and social history.  Provided records in this case do not document a 
comprehensive examination with a general multisystem examination or a complete examination of a single 
organ system.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99222 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99222 billed for date of service September 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 14, 2022, to 
February 12, 2022.  
You asked the Plan to pay for the home health services as billed. You say that you did submit the NOA, so it is 
on file. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 14, 2022, to 
February 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) respiratory panel 
(87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87486, 87798) provided on September 23, 2022. 
 
You asked the Plan to pay for the PCR respiratory panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing was not billed with a single panel code as required. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PCR respiratory panel have not been met. Therefore, we decided that the Plan does not have to pay for the polymerase chain reaction (PCR) respiratory panel (87496, 87498, 87502, 87532, 87541, 87581, 
87634, 87640, 87486, 87798) provided on September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for e CXbladder detect test (0012M) provided on April 6, 2022. 
 
You asked the Plan to pay for e CXbladder detect test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of e CXbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for e CXbladder detect test (0012M) provided on April 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on November 1, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says that this claim is denied. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no clear reason for denial in this case, nor has 
the Plan provided supporting evidence or a relevant citation. The Plan's denial is not substantiated in this case. 
Therefore, we decided that the Plan has to pay for laboratory services provided on November 1, 2021.  
 
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 the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on October 18, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on October 
18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Osteopathic Manipulation. 
 
You asked the Plan to pre-approve Osteopathic Manipulation. The Plan denied your request. The Plan says 
coverage for the requested service is not a covered benefit. 
 
 
 The Plan follows Medicare rules. Medicare rules say that Osteopathic Manipulative Treatment is not covered 
when the indication of Coverage is not met, and conventional documentation of somatic dysfunction is not 
present in the patient's medical record. 
 
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 Osteopathic Manipulation. Our 
reviewer says that Osteopathic Manipulation is not medically reasonable and necessary for the enrollee. Our 
physician reviewer found the enrollee has a history of Hashimoto's thyroiditis and polyarthritis. There is no 
specific clinical rationale for the requested Osteopathic Manipulation. Our reviewer found that the enrollee 
does not have a condition which is indicated for coverage. Our physician reviewer also found that there are not 
any limitations as listed in the LCD that would prevent coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Osteopathic Manipulation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Osteopathic Manipulation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 
36 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 73 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 15, 
2022. 
 You asked the Plan to pay for procedure code 86077. You say that the medical records support the necessity of 
this service. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service October 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve a Percutaneous Vertebral Augmentation (22514). 
 
You asked the Plan to pre-approve Percutaneous Vertebral Augmentation. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation ((PVA) is 
covered for an Acute (less than 6 weeks) or subacute (6-12 weeks) osteoporotic vertical compression fracture 
(T1  L5) confirmed by recent (within 30 days) advanced imaging. 
 
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 Percutaneous Vertebral Augmentation. 
Our reviewer says that this procedure is not medically necessary. Our physician reviewer found there is no 
documentation of imaging studies showing an acute fracture less than 6 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Percutaneous Vertebral Augmentation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Percutaneous Vertebral Augmentation (22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Leqvio. 
 You asked the Plan to pre-approve Leqvio. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 
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 Leqvio. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Repatha before they will approve the requested drug. The requested drug is a new 
start. 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 Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Leqvio.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGx Comprehensive Complete Cancer testing rendered 
on October 17, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
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, a CGx Comprehensive Complete Cancer panel, 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 CGx Comprehensive Complete Cancer testing rendered on October 17, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305) provided on May 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like your bill paid. The Plan 
denied your request. The Plan says the primary payer needs to review the services for payment before the Plan 
can review the claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
provider to explain that the claim must first be sent to the primary payer. As the secondary insurer, the Plan 
cannot be held responsible for the laboratory services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the laboratory services (88305) provided 
on May 24, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the CTA of the chest (71275). We decided that the Plan does not have 
to pay for the CTA of the abdomen and pelvis (74174).  
 
You asked the Plan to pay for the computed tomographic angiography (CTA) of the abdomen and pelvis 
(74174-26) and CTA of the chest (71275) provided on November 29, 2022. You say that you would like 
reconsideration based on the records submitted. The Plan says that the documentation submitted does not 
support the service billed. 
 
We decided that the Plan has to pay for the CTA of the chest (71275).  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE).  
 
We looked at the file, your request and Medicare rules. Based on this information we have determined the 
Medicare criteria for coverage have been met. Specifically, the Plan has not provided any sufficient evidence to 
support the denial of CPT code 71275. It is the burden of the Health Plan to support their denial with evidence. 
In this case, the Plans denial has not been substantiated so we must find in your favor. Therefore, we decided 
that the Plan has to pay for the CTA of the chest (71275).  
 
We also decided that the Plan does not have to pay for the CTA of the abdomen and pelvis (74174). 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly.  
 
We looked at the file, your request and Medicare rules. Based on this information we have determined the 
Medicare criteria for coverage have not been met. Specifically, the record shows that CPT code 74174 has been 
billed twice for the same date of service. The record also shows that the Plan paid for one unit of 74174. There 
is no evidence in the file to support that this service was provided more than once on the billed date of service. 
Therefore, we decided that the Plan does not have to pay for the CTA of the abdomen and pelvis (74174). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request for proton beam therapy 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 proton beam therapy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is insufficient prospective, long-term, clinical data available to determine whether or 
not proton beam radiation therapy for prostate cancer is superior, inferior, or equivalent to external beam 
radiation therapy, intensity-modulated radiation therapy (IMRT) or brachytherapy with regards to safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that the enrollee 
needs transportation to a facility. The Plan denied your request. The Plan says the routine transportation benefit 
only allows 48 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 263 miles away from the enrollee's residence. The Plan only covers distances up to 50 miles. Therefore, 
we decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency medical services provided on December 11, 
2022. 
 
You asked the Plan to pay for the services rendered. You say that this should be paid based on industry 
standards for out-of-network providers. The Plan denied your request. The Plan says the claim cannot be paid 
to this type of provider. 
 
The Plan must follow Medicare rules. Medicare rules say that emergency departments that are not affiliated 
with hospitals cannot be paid by Medicare.  
 
We looked at the file and Medicare rules. This is a freestanding emergency clinic that is not affiliated with a 
hospital. Based on this information, we decided that Medicare rules for coverage of the services rendered have 
not been met. Therefore, we decided that the Plan does not have to pay for the emergency medical services 
provided on December 11, 2022.