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

 
We decided that the Plan does not have to pre-approve Hyalran (J7321). 
 
You asked the Plan to pre-approve Hyalran. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Orthovisc and Supartz FX. 
 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 Hyalran. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs. The reviewer found that the documentation does not 
outline contraindications or reasons these medications were not considered. 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 Hyalran have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalran (J7321).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MLH1 (mutL homolog 1, colon cancer, nonpolyposis 
type 2) gene analysis (81288). 
 
You asked the Plan to pre-approve MLH1 gene analysis. You say that this testing is medically necessary for 
this enrollee. The Plan denied your request. The Plan says individual testing for this gene is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that individual genetic testing for the MLH1 gene is 
unlikely to impact therapeutic decision-making, directly impact treatment, outcome and/or clinical management 
in the care of the beneficiary and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. The requested individual gene testing is not considered medically 
necessary based on Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
MLH1 gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve 
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) gene analysis (81288).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 3, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 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 procedure code 70450 billed for date of service June 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the balloon sinuplasty (sinus ostial dilation (SOD)). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary due to atypical facial 
pain. The Plan denied your request. The Plan says the enrollee's records do not show that this procedure is 
being considered as an adjunct to FESS, that they have had prior sinus surgery, or that they have acute sinusitis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the 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 provided does not indicate the presence of documented sinus obstruction or recurrent 
infection. The requested service is not being performed in conjunction with functional endoscopic sinus 
surgery. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service for the enrollee's clinical condition at this time. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the balloon sinuplasty (sinus ostial dilation (SOD)).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71045) provided on July 25, 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 this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 19, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (71045) provided on July 25, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as a skilled nursing facility. 
 
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 was admitted to an acute hospital with confusion from medication, given for a compression fracture from a fall. The enrollee is medically stable and does not need a physician's close 
supervision three times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. There are no documented nursing needs. 
 
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 pay for procedure code 76642 billed for date of service September 6, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that these services were reported 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 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 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from March 21, 2021 to 
March 26, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed with the appropriate DRG. The Plan denied your request. The Plan says the DRG billed is not 
substantiate based on the records provided. 
 
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 N17.9, acute kidney failure, unspecified, G93.6, 
cerebral edema, and 148.92, unspecified atrial flutter. We asked our physician reviewer to carefully review the 
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 
pay for the inpatient hospital services at the DRG originally billed. Our reviewer says that the records do not 
support the diagnoses in question. Our physician reviewer found in this case, there was no clinical or laboratory 
evidence of acute kidney injury. While cytoxic cerebral edema was noted on MRI, there were no clinical 
interventions required and the enrollee's baseline EKG demonstrated atrial flutter which required no specific 
intervention. The review has determined that the records did not substantiate the billed DRG. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from March 21, 2021 to March 26, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the thoracic 
spine (72146). 
 
You asked the Plan to pre-approve an MRI of the thoracic spine. You say that you need an MRI because you 
are in a lot of pain. The Plan denied your request. The Plan says you do not meet the guideline based on the 
records reviewed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the thoracic spine. Our 
physician reviewer found during the last documented encounter on August 15, 2022, nothing unusual was 
found on physical exam and you were referred to an Orthopedic specialist for evaluation and recommendations 
for imaging and therapeutic intervention. The orthopedic referral has been made but there is no evaluation by 
an orthopedist in the submitted records. Our reviewer found there is no thoracic spine x-ray series in the 
records. You have had a physical therapy evaluation but have only had 3 sessions and are apparently doing a 
home exercise regimen. Our physician reviewer also found that absent an evaluation by the orthopedic 
specialist and due to no red flags evident in the submitted records the medical necessity of the requested MRI 
of the thoracic spine has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the thoracic spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the thoracic spine (72146).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endoscopic pyloromyotomy. 
 
You asked the Plan to pre-approve endoscopic pyloromyotomy. You say that the records provided support the 
need for the requested services. The Plan denied your request. The Plan says that the requested service is 
considered experimental, investigational, and unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 endoscopic pyloromyotomy. Our 
reviewer says that endoscopic pyloromyotomy is considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has diagnoses of gastroparesis with significant gastric retention, and 
GERD. The enrollee has severe symptoms despite daily therapy with a proton-pump inhibitor (PPI.) Gastric 
peroral endoscopic pyloromyotomy has been shown to be an effective treatment option for patients with 
refractory gastroparesis and should be considered in such cases. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endoscopic pyloromyotomy have been met. Therefore, we decided that the Plan 
has to pre-approve endoscopic pyloromyotomy.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan 
provided on June 01, 2021, to July 08, 2021. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) scan. You say that this is 
a duplicate bill, you should not have to pay so much money. 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 a $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for a magnetic resonance imaging (MRI) scan. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies 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. You have a $50 copayment x 2 visits = 
$100 total. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
imaging (MRI) scan provided on June 01, 2021, to July 08, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded 99284 
provided on August 12, 2022. 
 
You asked the Plan to pay for the evaluation and management services coded 99284. You say that the 
documentation supports the evaluation and management services as they were billed. The Plan denied your 
request. The Plan says there is a more appropriate CPT code to bill for the services rendered. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate 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 require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function. 
 
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 evaluation and management services coded 99284. Our 
reviewer says that the documentation does not support payment for CPT code 99284. Our reviewer found that 
the review indicates that the member was stable, with normal vital signs and normal lab work. There was no 
sign of multiple system dysfunction nor a need for specialty consultation. The presentation was not one of high 
severity requiring urgent evaluation and no acute situation of a complex nature to support the level of care 
billed. The review has determined that the documentation did not support procedure code 99284. 
 
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 evaluation and management services coded 99284 have not been met. 
Therefore, we decided that the Plan does not have to pay for the evaluation and management services coded 
99284 provided on August 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 8, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (PSG) (95811). 
 
You asked the Plan to pre-approve a PSG. You say that you tried a sleep home study but were unable to use the 
equipment, and did not feel like you were able to get accurate information. The Plan denied your request. The 
Plan says you do not meet the criteria for coverage because you were diagnosed in 2021, and there was no 
change in weight or medical condition since your last study. 
 
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 PSG. Our reviewer says that an 
attended PSG with positive airway pressure (PAP) titration is not medically necessary. Our physician reviewer 
found you have a diagnosis of obstructive sleep apnea, made on a home sleep study in August 2021. You were 
reportedly intolerant of continuous positive airway pressure (CPAP), but the nature of the intolerance is not 
given. Our reviewer found there is no comment on whether the problem was related to the mask/interface, and 
if so, what other interfaces were tried. Repeating a sleep study would not be expected to address the PAP 
intolerance issue. Our physician reviewer also found that there is no indication you would be willing to try 
CPAP again. 
 
 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 PSG have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a polysomnography (PSG) (95811).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays provided on July 25, 2022, to 
September 01, 2022. 
 
You asked the Plan to waive the copayment for x-rays. You say that this should be covered. 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 a $35 
copayment for X-rays. 
 
You have been asked to pay a $35 copayment for x-rays. This item/service falls within the X-rays 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. You have been 
asked to pay a total of $101.08 which is less than the standard $35 per x-ray cost. Therefore, we decided that 
the Plan does not have to waive the copayment for x-rays provided on July 25, 2022, to September 01, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail one intravenous bisphosphonate therapy first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the Plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.