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

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
October 21, 2021. 
 
You asked the Plan to pay for the emergency department visit coded 99285. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 We find that CPT code 99285 is not supported in the medical record. Specifically, the documentation does not 
support high severity immediate significant threat to life. The enrollee had no life threatening illnesses and was 
documented as stable. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit coded 99285 have not been met. Therefore, we decided that the Plan does not have 
to pay for the emergency department visit coded 99285 provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Observation care discharge day management (99217) 
provided on January 16, 2022. 
 
You asked the Plan to pay for code 99217. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. The rules also say that when a patient is 
admitted for observation care and then is discharged on a different calendar date, the physician shall report 
Initial Observation Care, from CPT code range 99218 - 99220, and CPT observation care discharge CPT code 
99217. 
 We looked at the file and Medicare rules. In this case, the medical documentation indicates that the enrollee 
discharged from observation care on January 16, 2022. There is no documentation provided that the appropriate 
qualifying initial observation care procedure code was billed. Without this code, the observation care discharge 
day management coded as 99217 is not eligible for payment. Therefore, we decided that the Plan does not have 
to pay for the Observation care discharge day management (99217) provided on January 16, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the over-the-counter COVID-19 home testing kit provided on January 
26, 2022. 
 
You asked the Plan to pay for the over-the-counter COVID-19 home testing kit. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are 
not covered. 
 
The Plan must follow Medicare rules. CMS says that Plans and insurers are required to cover at-home over-the-
counter COVID-19 tests purchased on or after January 15, 2022.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the At-Home coronavirus tests have been met. Specifically, the At-Home coronavirus tests were 
purchased after the date of January 15, 2022. Therefore, we decided that the Plan has to pay for the over-the-
counter COVID-19 home testing kit provided on January 26, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve LTACH services. You say that LTACH services are medically necessary as 
the enrollee is ready for the next level of care to continue her treatment plan. The Plan denied your request. The 
Plan says the enrollee is receiving appropriate inpatient care at the current hospital and is currently unstable for 
transfer. 
 
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 that the enrollee does not require services at the LTACH that are not already 
available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve above the knee amputation services. 
 
You asked the Plan to pre-approve above the knee amputation services. You say that this procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have 
not been met. 
 
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 above the knee amputation services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the record indicates that the enrollee is a paraplegic and suffered femur 
fractures after a fall. The record does not document the presence of an accepted indication for the requested 
services. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules,  of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not 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 above the knee amputation services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve above the knee amputation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Segmental pneumatic appliance for use with pneumatic 
compressor, trunk (E0656) provided on October 7, 2021. 
 
You asked the Plan to pay for code E0656. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules state that HCPCS code E0656 cannot be used when billing for 
appliances used with E0676 devices. The file shows that the Plan paid for an E0676 device on the same claim 
at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the Segmental pneumatic 
appliance for use with pneumatic compressor, trunk (E0656) provided on October 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) 
provided on November 27, 2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that the services were 
necessary, and payment should be rendered. The Plan denied your request. The Plan says the service is non-
covered by Medicare. 
 
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 81455 has a Status Indicator of X on the Physician Fee Schedule. This means that CPT 
code 81455 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the targeted genomic sequence analysis panel (81455) provided on November 27, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an implantable loop recorder (ILR). You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that placement of an ILR is only covered for certain 
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 placement of an implantable loop 
recorder (ILR). Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found the enrollee has a history of atrial fibrillation. 
There is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any 
other apparent indication for an ILR. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an implantable loop recorder (ILR) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial vulvectomy services. 
 
You asked the Plan to pre-approve partial vulvectomy services. You say that this surgery is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested surgery is considered 
cosmetic in nature. 
 
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 partial vulvectomy services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has hypertrophy of right labia minora 
that causes pain particularly when seated. The record does not indicate the presence of any lesions or rashes. 
The record does not indicate that expectant management has been trialed. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. The requested service is not 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 partial vulvectomy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve partial vulvectomy services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 
You asked the Plan to pre-approve Evenity. You say that although it is not Food and Drug Administration 
(FDA) approved, an Evenity study shows to be safe and effective in men with osteoporosis. The Plan denied 
your request. The Plan says Evenity is FDA approved for treatment of osteoporosis in men, but it is not 
approved for treatment of osteopenia for anyone of any gender. The Plan also says that as the enrollee has 
osteopenia, not osteoporosis, treatment with Evenity is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Evenity. Our reviewer says that Evenity 
is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that Evenity is indicated for the enrollee's condition. Our reviewer found 
that the Medicare approved drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. Our physician 
reviewer also found that the requested service cannot be 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that this drug is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox is covered when the enrollee has headache 
with at least two of the following:  
I. unilateral location 
II. pulsating quality 
III. moderate or severe pain intensity 
IV. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)  
We looked at the file and Medicare rules. In this case, the enrollee does not have evidence of 5 headaches with 
a least two of the following: headache with unilateral location, pulsating quality, moderate or severe pain 
intensity or aggravation by or causing avoidance of physical activity. Based on this information, we decided 
that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary as you need 
therapy for your weakness after the fracture of your pelvis. The Plan denied your request. The Plan says you do 
not meet criteria for SNF care and the services you require is called custodial care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our physician reviewer 
found that you do not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 10, 2021. 
 
You asked the Plan to pay for psychotherapy. You say that the practice made multiple calls to confirm 
eligibility and were told the Plan would cover the services even if you weren't a Medicare provider. The Plan 
denied your request. The Plan says this provider is not eligible to be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain individuals and entities that 
frequently attempt to enroll in Medicare but are not eligible to do so.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, a Mental Health Counselor is not eligible for 
Medicare payment. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on October 15, 2020. 
 
You asked the Plan to pay for the refraction. You say that this claim was for a medical eye exam that was 
already processed and paid. You say that payment was not received, and you want to know when to expect 
reimbursement. The Plan denied your request. The Plan says the medical eye exam has been overturned and the 
refraction remains denied as a non-covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a refraction when performed with a routine eye exam. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the refraction have not been met. Specifically, a routine eye exam was not performed. Therefore, 
we decided that the Plan does not have to pay for the refraction provided on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assay of calcium (82310), assay of parathormone 
(83970), and assay of phosphorus (84100) provided on December 6, 2021. 
 
You asked the Plan to pay for the assay of calcium, assay of parathormone, and assay of phosphorus. You say 
that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says 
the services were not billed in accordance with Medicare policy. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of ESRD are included in the ESRD PPS as Part B services and are not paid separately as of 
January 1, 2011.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the assay of calcium, assay of parathormone, and assay of phosphorus have not been met. Therefore, we decided that the Plan does not have to pay for the assay of calcium (82310), assay of 
parathormone (83970), and assay of phosphorus (84100) provided on December 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on December 16, 2021. 
  You asked the Plan to pay for the CT scan (70450). You say that the patient had multiple exams on this date of 
service and the reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code 
edit. 
 
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 70450 
is a column II code to column I code 70496. 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 CT scan (70450) provided on December 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan services (93976) provided on January 21, 
2022. 
 
You asked the Plan to pay for the duplex scan services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this code is not separately payable 
according to Medicare billing 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 93976 
is a column II code to column I code 76856. 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 duplex scan services (93976) provided on January 21, 2022.