Persius/hicric huggingface dataset:
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 you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of postmenopausal osteoporosis with a vertebral compression fracture. While 
the documentation shows that the enrollee was on Fosamax for 6-7 years but was taken off of the drug in 2018 
for unspecified reasons. The documentation does not support that the enrollee has tried and failed an 
intravenous bisphosphonate. The documentation does not support that an intravenous bisphosphonate would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit (G0402, G0463) provided on August 23, 
2022. 
 
You asked the Plan to pay for the outpatient visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code G0402, & G0463 is not supported in the medical record. Specifically, multiple visits on 
the same day were reported without condition code G0 reported. Based on this information, we decided that 
Medicare rules for coverage of the outpatient visit have not been met. Therefore, we decided that the Plan does 
not have to pay for an outpatient visit (G0402, G0463) provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99151) provided on July 10, 2022. 
 
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says the billed 
code 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 99151 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient 
younger than 5 years of age". 
 
We find that CPT code 99151 is not supported in the medical record. Specifically, the provided records do not 
show that the enrollee in this case is younger than 5 years of age. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services (99151) provided on July 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tinnitus assessment (92625) provided on September 22, 
2022. 
 
You asked the Plan to pay for a tinnitus assessment. You say that you should be reimbursed for the full cost of 
this service. The Plan denied your request. The Plan says the allowed amount for this service has been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tinnitus assessment have not been met. Specifically, the record indicates that the Plan has paid 
the Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed 
amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the 
Medicare allowed payment. Therefore, we decided that the Plan does not have to pay for a tinnitus assessment 
(92625) provided on September 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services to fuse a single level in the enrollee's lower 
back (CPT code(s): 20930, 22840 and 22612). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says interspinous process fusion devices are not proven and medically necessary 
when used as stand-alone lumbar vertebral fusion procedure. 
 
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 interspinous process fusion devices are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve services to fuse a single level in the enrollee's lower back (CPT code(s): 20930, 22840 and 
22612).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on October 5, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. 
Therefore, we decided that the Plan does not have to pay for the PrismRA test provided on October 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service October 30, 
2022. 
 You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 
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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service October 30, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says more research is needed to show safety and efficacy of the procedure. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on May 2, 2022. 
 
You asked the Plan to pay for lab services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this claim is a duplicate that was already considered for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied payment for this claim on the basis that it is a duplicate. 
However, the Plan did not submit any original claim or other evidence to support that this claim is a duplicate. 
The Plan did not provide any other evidence or rationale to support a denial of payment. Therefore, we decided 
that the Plan has to pay for laboratory services provided on May 2, 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 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 request is not medically necessary because the 
enrollee is receiving the care they need in the hospital where they are now and there is no need to transfer to the 
LTACH 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 the enrollee can remain at the current ACH until such time no acute services are 
required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC 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 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 a partial hospitalization. 
 
You asked the Plan to pre-approve a partial hospitalization. You say that the enrollee requires partial treatment 
to neutralize acute depressive and anxiety symptoms to prevent further acute hospitalization. The Plan denied 
your request. The Plan says the enrollee does not present acute symptoms or psychosocial factors that represent 
imminent risk or potential imminent risk to themself, others, or their property. The Plan also says documented 
clinical findings do not justify the level of care requested. 
 
The Plan follows Medicare rules. Medicare rules say that partial hospitalization is a distinct and organized 
intensive treatment program for patients who would otherwise require inpatient psychiatric care. 
 
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 partial hospitalization. Our reviewer 
says that the enrollee does not meet the Medicare criteria for a partial hospitalization. Our physician reviewer 
found this enrollee was not showing any dangerousness to self or others and has not been exhibiting severe 
psychological or psychiatric impairment requiring this level of care. The enrollee was not showing any 
perceptual disturbance, psychosis or aggressive behaviors. Our reviewer also found that it does not appear 
medically necessary and reasonable to have psychiatric care provided at the partial hospitalization level of care 
rather than 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 a partial hospitalization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a partial hospitalization.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from March 16, 
2021, to March 21, 2021. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that a present on admission (POA) indicator is 
required for all inpatient hospital claims. 
 
We looked at the file and Medicare rules. The file shows that a POA indicator encompassing all billed 
diagnoses was not submitted on the claim. Therefore, we decided that the Plan does not have to pay for the 
inpatient hospital services rendered from March 16, 2021, to March 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96361, 96375, 96413, and J9177 billed for 
July 21, 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 procedure codes 96361, 96375, 96413, and J9177 are 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 96361 is intravenous infusion, hydration; each additional 
hour (List separately in addition to code for primary procedure). The definition of code 96375 is therapeutic, 
prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of 
a new substance/drug (List separately in addition to code for primary procedure). The definition of code 
chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. 
The definition of code J9177 is injection, enfortumab vedotin-ejfv, 0.25 mg. 
 
We find that CPT codes 96361, 96375, 96413, and J9177 are not supported in the medical record. Specifically, 
there is no documentation of administration of the drug with a documented route of administration and clear start and stop times. 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 procedure codes 96361, 96375, 
96413, and J9177 billed for July 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 50200 billed for date of service September 8, 
2022. 
 You asked the Plan to pay for procedure code 50200. You say that you disagree with the denial. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 50200 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 50200 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 50200 billed for date of service September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve angioplasty, atherectomy, and stents. 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says a trial of structured exercise is suggested, with walking exercises for at least 12 
weeks, as well as use of a medication for 12 weeks. 
 
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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation does not support the medical necessity of the procedures in 
question.  The patient has a history of leg pain with walking less than twenty yards and needs a grocery cart for 
support. The enrollee was recently evaluated for anemia and internal bleeding but unclear if a source was 
found and treated. There is no documentation suggesting limb threat. The symptoms are out of proportion to 
the objective vascular findings and are suggestive of a neurogenic process. The enrollee has undergone 
numerous relatively recent revascularization procedures. Recent evaluation also suggests generalized 
weakness. As there is no evidence of limb threat and it is not clear that the additional procedures will provide 
meaningful improvement in the patients quality of life, this cannot be overturned on the basis of medical necessity. 
 
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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve angioplasty, atherectomy, and stents.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies.. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage of CGMs and related 
supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The available medical documentation does not indicate that you 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a CGM and related supplies. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and 
related supplies.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Opioid treatment programs provided on August 15, 2022. 
 
You asked the Plan to pay for Opioid treatment programs. You say that the facility is enrolled in the Medicare 
program to provide Opioid treatment programs services since January 01, 2020. The Plan denied your request. 
The Plan says individual providers cannot bill for OTP services.  
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Opioid treatment programs have not been met. Therefore, we decided that the Plan does not have 
to pay for Opioid treatment programs provided on August 15, 2022.