Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A9270-GY billed for date of service September 23, 
2022. 
 
You asked the Plan to pay for code A9270-GY. You did not provide a specific argument for coverage of this 
code. The Plan denied your request. The Plan says this code is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code A9270 represents non-covered items or 
services. There are no scenarios where this code will be covered under Medicare. Therefore, we decided that 
the Plan does not have to pay for code A9270-GY billed for date of service September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (75710) provided on April 19, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
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 75710 is not supported in the medical record. Specifically, the angiography service is 
included in the billed interventional vascular procedure (37227). Based on this information, we decided that 
Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan 
does not have to pay for radiology services (75710) provided on April 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that the requested drug is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Stelara. 
 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 Entyvio. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred drug. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred drug. Therefore, the reviewer 
found that the step therapy criteria have not 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), endoskeletal knee-shin system, fluid stance extension, dampening 
feature (L5848), stance phase only (L5858), and endoskeletal, knee-shin system, stance flexion feature 
(L5845). 
 
You asked the Plan to pre-approve a fluid swing and stance phase control, fluid stance extension, stance phase 
only, and stance flexion feature. You say that a custom fabricated transfemoral prosthesis including a 
micropressor-controlled knee (L5828, L5845, L5848, and L5856) is medically necessary to enable this enrollee 
to reach their rehabilitation potential. The Plan denied your request. The Plan says this request for a level 3 
(K3) microprocessor knee does not meet Medicare criteria as reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
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 fluid swing and stance phase control, 
fluid stance extension, stance phase only, and stance flexion feature. Our reviewer says that a fluid swing and 
stance phase control, fluid stance extension, stance phase only, and stance flexion feature are not medically 
reasonable and necessary for the enrollee. Our physician reviewer found the documentation indicates the 
enrollee is expected to ambulate at a K3 functional level. Our reviewer also found that the medical 
documentation available for review does not clearly indicate that the enrollee requires a microprocessor knee in 
place of the authorized knee. 
 
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 fluid swing and stance phase control, fluid stance extension, stance phase 
only, and stance flexion feature have not been met. Therefore, we decided that the Plan does not have to pre-
approve an endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), 
endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848), stance phase only (L5858), 
and endoskeletal, knee-shin system, stance flexion feature (L5845).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2022, to October 7, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2022, to October 7, 2022.
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 this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show the enrollee needs continued 
treatments that can only be given in a hospital setting, When they are ready to leave the hospital, they can 
safely receive this care in another setting, such as a Skilled Nursing Facility (SNF). 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Northera. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Northera.  
 
Benefits for these services 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 lab services provided on July 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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, for 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 July 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT) test (78830). 
 
You asked the Plan to pre-approve a SPECT test. You say that the enrollee needs SPECT. The Plan denied 
your request. The Plan says SPECT is not the correct imaging study to re-stage known prostate cancer. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary for patients experiencing new, recurrent, or worsening cardiac symptoms, 
including otherwise unexplained angina equivalent symptom. 
 
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 SPECT test. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that you have known prostate cancer, 
diagnosed in 2012, and declined treatment at that time. Recent prostate-specific antigen (PSA) increased to 
28.4 on March 22, 2022. You do not want treatment but want to follow the progression of your prostate cancer 
with PSA and imaging. You declined an updated biopsy. The most recent images were from 2021 bone scan 
showing no mets and computed tomography (CT) abdomen/pelvis no mets. SPECT (78830) was requested. 
SPECT is not the correct imaging study to re-stage known prostate cancer. There was no other information 
provided supporting this request. Therefore, the SPECT will be considered not medically necessary as the 
criteria is not 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 a SPECT test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single photon emission computed tomography (SPECT) test (78830).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar laminectomy (63047). 
 
You asked the Plan to pre-approve a lumbar laminectomy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 a lumbar laminectomy. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures outside of a lumbar epidural steroid injection. There is 
no detailed evidence of severe and/or progressive neurological abnormalities or red-flag findings. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 lumbar laminectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar laminectomy (63047).
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 the enrollee needs intensive physical and 
occupational therapy with full time access to a physician with training in rehabilitation. The Plan denied your 
request. The Plan says the enrollee's records do not show the need an intensive team for your care, nor the need 
to be seen by a rehabilitation doctor at least three times a week for evaluation of functional and medical goals 
and progress, medically necessary care may be provided safely in a different level of care. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a diagnostic colonoscopy, pathology 
services, and Part B drugs provided on July 1, 2022. 
 
You asked the Plan to waive the cost share for a colonoscopy, pathology services, and Part B drugs. You say 
that you should not have a cost share amount for the colonoscopy. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $325 
copayment for an in-network diagnostic colonoscopy. The Plan contract also says that enrollees must pay a $10 
copayment for in-network lab services and 20% coinsurance for in-network Part B drugs. 
 You have been asked to pay $315, which is less than the standard $325 copayment for a diagnostic 
colonoscopy ($238.11 copayment + $76.89 copayment = $315). This item/service falls within the outpatient 
surgery benefit category. You have also been asked to pay a $10 copayment for pathology services. This 
item/service falls within the outpatient diagnostic tests and services benefit category. 
 
You have been asked to pay $3.13, which is 20% coinsurance of the allowed amount for Part B drugs ($15.66 
allowed amount x 20% coinsurance = $3.13). You have also been asked to pay $5.86, which is 20% 
coinsurance of the allowed amount for Part B drugs ($29.32 allowed amount x 20% coinsurance = $5.86). You 
have been asked to pay a total of $333.99. These items/services fall within the Medicare Part B prescription 
drug benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost share for a diagnostic colonoscopy, 
pathology services, and Part B drugs provided on July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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, for 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 July 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76641 billed for date of service November 
9, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 76641 billed for date of 
service November 9, 2022.  
 
In addition, we have confirmed that code 77063 is a column II code to column I code 77065. 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 have decided that the plan does not have to pay for code 77063 billed 
for the date of service November 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 provided on July 26, 2022. 
 
You asked the Plan to pay for code 99223. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the service billed is 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 99223 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 high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
 
 We asked our physician 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 99223. Our reviewer says that the documentation 
does not support the code billed. Our reviewer found the enrollee was evaluated after a ground level fall. The 
evaluation revealed a left hip fracture and a fracture the superior pubic ramus. This initial hospital care 
evaluation and management code requires a comprehensive history a comprehensive examination and medical 
decision making of high complexity However the medical records submitted did not support medical decision 
making of high complexity. Therefore, code 99223 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 provided on July 26, 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 the services are medically necessary for the enrollee 
to get the care needed. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided safely in another setting such as, a skilled nursing facility, home with home health services or home 
with outpatient therapy. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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.