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

 
We decided that the Plan does not have to pre-approve biomarker testing for myeloproliferative disease. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that biomarker testing is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of essential 
(hemorrhagic) thrombocythemia. Laboratory testing documents a normal WBC concentration as well as a 
hemoglobin of 16.1 and hematocrit of 47.3. The platelet count is elevated at 501K. There are no abnormal cells 
seen on peripheral blood cytology. The enrollee has had no bone marrow in over two years and there is no 
diagnosis of definite malignancy to justify the cost or usefulness of this genetic testing with isolated 
thrombocytosis alone. The criteria for coverage are not met and the testing is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve biomarker testing for myeloproliferative disease.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for therapeutic intravenous (IV) infusions 
provided from May 7, 2021, to May 25, 2021. 
 
You asked the Plan to waive the copayments for IV infusions. You say that these services were administered by 
a nurse not a physician. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 a $20 
copayment for in-network Part B drugs administered by a primary care provider. The contract also says that 
you must pay a $25 copayment for in-network Part B drugs administered by a specialty care physician.   The medical records show that there was a supervising physician overseeing each of the infusions you received 
from May 7, 2021, to May 25, 2021. You have been asked to pay a total of $405 for IV infusions. IV infusions 
fall within the Medicare Part B Prescription Drugs benefit category.  
 
Date of Service Copayment 
May 7, 2021 $20 
May 8, 2021 $25 
May 9, 2021 $25 
May 10, 2021 $20 
May 11, 2021 $25 
May 12, 2021 $25 
May 13, 2021 $25 
May 14, 2021 $20 
May 16, 2021 $25 
May 17, 2021 $20 
May 18, 2021 $25 
May 19, 2021 $25 
May 21, 2021 $25 
May 22, 2021 $25 
May 23, 2021 $25 
May 24, 2021 $25 
May 25, 2021 $25 
Total $405 
 
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 copayments for therapeutic intravenous (IV) infusions provided from May 
7, 2021, to May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of a neurostimulator 
electrode array, peripheral nerve (64555). 
 
You asked the Plan to pre-approve a percutaneous implantation of a neurostimulator electrode array. You say 
that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says 
rules 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 a percutaneous implantation of a 
neurostimulator electrode array. Our reviewer says that the requested service is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the requested service is considered 
experimental/investigational for the pain of osteoarthritis. 
 
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 percutaneous implantation of a neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of a 
neurostimulator electrode array, peripheral nerve (64555).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device 
(Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex procedure. You say that the enrollee has failed conservative 
treatments and is a good candidate for Vertiflex. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because Vertiflex is experimental/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 pre-approve Vertiflex procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic or therapeutic injections (62320), provided on 
December 13, 2021. 
 
You asked the Plan to pay for the diagnostic or therapeutic injection. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the required clinical records to support medical 
necessity of this service have not been submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the diagnostic or therapeutic injections 
(62320), provided on December 13, 2021. have been met. The records provided are not signed or dated and do 
not show medical necessity. Therefore, we decided that the Plan does not have to pay for the diagnostic or 
therapeutic injections (62320), provided on December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on October 6, 
2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you should not have to pay the 
copayment because this second surgery was due to complications from your initial surgery. The Plan denied 
your request. The Plan says copayment is correct. 
 
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 $300 
copayment for Medicare-covered services provided in an ambulatory surgical center.  
 
  You have been asked to pay $300 copayment for cataract surgery. Cataract surgery falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayment for cataract surgery provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection(s), of diagnostic or therapeutic substance 
(62320), provided on November 22, 2021. 
 
You asked the Plan to pay for the lumbar injections. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the required clinical records to support the medical necessity of this service 
have not been submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the injection(s), of diagnostic or 
therapeutic substance (62320), provided on November 22, 2021. have been met. the records provided to the 
Health Plan are undated and unsigned. Therefore, we decided that the Plan does not have to pay for the 
injection(s), of diagnostic or therapeutic substance (62320), provided on November 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition.  The 
enrollees care needs, as a practical matter, can be provided at a lower 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
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 the LTACH services. You say that LTACH admission is medically 
necessary. The Plan denied your request. The Plan says you are receiving appropriate in-patient acute care 
currently. 
 
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 all medically necessary care is being provided in the current acute care 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time 
(99072) provided on October 7, 2021. 
 
You asked the Plan to pay for the additional supplies, materials, and clinical staff time (99072). You say that 
the medical records required to reprocess the denied claim are attached. The Plan denied your request. The Plan 
says procedure code 99350 has been paid and procedure code 99072 remains denied as bundled services are not 
eligible for separate reimbursement.  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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the additional supplies, materials, and clinical staff time (99072) have not been met. Therefore, we decided 
that the Plan does not have to pay for the additional supplies, materials, and clinical staff time (99072) provided 
on October 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided 
from August 27, 2021, to August 30, 2021. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the provided documentation 
supports the billing of the principal diagnosis code, A41.59. The Plan denied your request. The Plan says the 
principal diagnosis code A41.59, other gram-negative sepsis, is not supported. 
 
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 principal diagnosis code, A41.59, other gram-
negative sepsis. 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 an additional amount for the 
inpatient care. Our reviewer says that the principal diagnosis code was not supported. Our physician reviewer 
found the provided documentation does not indicate there was clinical or laboratory evidence for sepsis. 
Therefore, the reviewer found that the provided documentation did not support the billing of the principal 
diagnosis code A41.59, other gram-negative sepsis.  
 
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 
an additional amount for the inpatient hospital care provided from August 27, 2021, to August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) lead 
wires rendered on January 3, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that during the rental of a TENS unit, supplies for the unit 
are included in the rental allowance; there is no additional allowance for lead wires. 
 
We looked at the file and Medicare rules. The file shows that the lead wires were rendered during the rental 
period of the TENS. There is no coverage for additional lead wires. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the transcutaneous electrical nerve stimulation (TENS) lead wires rendered on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic or therapeutic injection (62320), provided on 
November 29, 2021. 
 
You asked the Plan to pay for the diagnostic or therapeutic injection. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the medical records submitted are insufficient. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the diagnostic or therapeutic injection 
(62320), provided on November 29, 2021. have been met. Specifically, the medical records submitted are 
insufficient; they are not signed, dated, or show medical necessity. Therefore, we decided that the Plan does not 
have to pay for the diagnostic or therapeutic injection (62320), provided on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic or therapeutic injection (62320), provided on 
November 22, 2021. 
 
You asked the Plan to pay for the diagnostic or therapeutic injection. You say that the service was medically 
necessary. The Plan denied your request. The Plan says insufficient medical records were submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the diagnostic or therapeutic injection 
(62320), provided on November 22, 2021. have been met. the medical records submitted are insufficient; they 
are not signed, dated or indicate medical necessity. Therefore, we decided that the Plan does not have to pay for 
the diagnostic or therapeutic injection (62320), provided on November 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on February 20, 2021, to February 28, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the provider billed KAGC1, but the 
plan says KDKC1 is more appropriate. On 11/27/20, it is documented that the enrollee had new expressive 
aphasia, transient. On 11/28/20 it is documented that the enrollee had apparent expressive aphasia. On 11/29/20 
it is documented that the enrollee had new expressive aphasia, transient. It is noted that the enrollee appeared to 
have recovered her speech temporarily, and then relapsed into nonverbal status 2 times. The case file contains 
documentation of decubitus ulcers, which would confirm special care low, and a nursing function score of 6-
14. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee on February 20, 2021, to 
February 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the thorax. 
 
You asked the Plan to pre-approve a CT scan of the thorax. The Plan denied your request. The Plan says a CT 
scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the thorax. Our reviewer 
says that a CT scan of the thorax is not medically necessary. Our physician reviewer found that the enrollee has 
no peripheral lymphadenopathy. The CT scan of the chest provided on November 9, 2021 was stable with no 
change in the benign appearing 1.4 cm pre carinal lymph node. The note by Aida Jones, CNS, from 
hematology on March 29, 2022, described a plan for a 1-year follow-up CT scan which would be in 
November 2022. The medical necessity of the requested CT chest before the planned 1-year follow-up has not 
been established in the records provided. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the thorax have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the thorax.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (97810) acupuncture, 
each additional 15 minutes (97811) provided September 22, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that please reimburse you as you had paid cash 
for this bill. The Plan denied your request. The Plan says this service is not covered when rendered by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 
minutes (97811) provided September 22, 2021.