Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 12, 2020, 
through March 15, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the review indicates that the enrollee presented to the emergency department (ED) on March 12, 
2020 after a fall at home. The evaluation in the ED included a computed tomography (CT) scan of the head 
which was normal. The urinalysis did show positive for a urinary tract infection and also positive for a urine 
drug screening for benzodiazepines and opiates but it was not clear if these were prescribed medications or not. 
She was admitted and treated with intravenous antibiotics. She was evaluated by Psychiatry. Her condition 
stabilized and improved and she was discharged on March 15, 2020. The review indicates that the record 
showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from March 12, 2020, through March 15, 2020.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx pen 
 
You asked the Plan to pre-approve Cosentyx. You say that the enrollee has trialed this medication previously 
with good benefits. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cosentyx pen  
 Benefits for Cosentyx may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper 
or lower extremity arteries (93922) provided on July 27, 2022. 
 
You asked the Plan to pay for the diagnostic service. You say that this should be paid. 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 6, 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 diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic 
studies of upper or lower extremity arteries (93922) provided on July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the enrollee's condition did not meet the rules for 
approval. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records do not show that the 
testing of 22 or more drug classes was indicated based on clinical history or risk assessment. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code G0483 billed for date of service July 27, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the external mobile cardiovascular telemetry (93229) services provided 
on May 19, 2022. 
 
You asked the Plan to pay for the external mobile cardiovascular telemetry services. 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. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the external mobile cardiovascular telemetry services by a contract provider. The file 
does not show that the Plan provided notice that the external mobile cardiovascular telemetry services would 
not be covered. Under Medicare rules, this means the external mobile cardiovascular telemetry services are 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the external mobile 
cardiovascular telemetry (93229) services provided on May 19, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vivex Biologics Via Graft allograft. 
 
You asked the Plan to pre-approve Vivex Biologics Via Graft allograft. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria 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 Vivex Biologics Via Graft allograft. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Vivex Biologics Via Graft Allograft, in this case, is not medically reasonable or 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 Vivex Biologics Via Graft allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Vivex Biologics Via Graft allograft.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan (70490) provided on May 
25, 2022. 
 
You asked the Plan to pay for the CT scan. You say that this claim has been updated and should be paid. The 
Plan denied your request. The Plan says this claim was submitted with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that services rendered to a patient who is registered 
inpatient or outpatient of a hospital should be billed with the appropriate inpatient or outpatient POS code 
regardless of where the actual face-to-face service took place.  
 We looked at the file and Medicare rules. The record shows that on the date in question, the enrollee was 
inpatient status. However, the submitted claim shows POS code 22  outpatient hospital. Because the enrollee 
was inpatient status on this date, the correct POS code would be the inpatient code. Based on this information, 
we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the 
Plan does not have to pay for computed tomography (CT) scan (70490) provided on May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assay of iron (83540) provided on May 6, 2022. 
 
You asked the Plan to pay for assay of iron. You say that this test was necessary and should be paid. The Plan 
denied your request. The Plan says this service was provided as part of a screening and is therefore not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, assay of iron, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for assay 
of iron (83540) provided on May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 billed for date of service February 
18, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88360. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88360 billed for date of service February 18, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70490 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 70490. You say that this was a separate and distinct service. The 
Plan denied your request. The Plan says 70490 cannot be billed on the same date as 70491 for the same 
enrollee by providers of the same specialty within the same group. 
 
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 70490 
is a column II code to column I code 70491 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 70490 billed for date of service April 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 
16, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that this should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 
16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74181 billed for date of service July 27, 
2022. 
 You asked the Plan to pay for procedure code 74181. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74181 is bundled into payment for 
code 74183. 
 
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 74181 
is a column II code to column I code 74183. 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 74181 billed for date of service July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on December 7, 2021 
to December 9, 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. The Plan denied your 
request. The Plan says the billed DRG 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 diagnosis codes J96.01 and N17.9. 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 use of diagnosis codes J96.01 and N17.9 is not supported by the records provided. 
Our physician reviewer found that the enrollee presented to the emergency department on December 7, 2021, 
after a colonoscopy earlier in the day. She was given Propofol for the procedure. She complained of nausea, 
vomiting and chest pain. On evaluation her vital signs were stable, oxygen saturation was 96% on room air, and 
labs revealed a creatinine of 0.92. She was admitted with diagnoses of aspiration pneumonia and chest pain. In 
this case, there was no clinical or laboratory evidence of acute respiratory failure with hypoxia or acute renal 
failure.  
 
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 the inpatient hospital services provided on December 7, 2021 to December 9, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (breast ductal carcinoma in situ) (DCISionRT) 
(0295U) provided February 15, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that your testing can provide guidance that can 
help determine if radiation therapy is necessary and the severity of it being a part of the enrollee's treatment. 
The Plan denied your request. The Plan says this service is considered experimental and investigational. 
DCISionRT is not approved by the FDA and not supported by NCCN guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the oncology (breast ductal carcinoma in situ) (DCISionRT) (0295U) provided February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 and 99140 billed for date of service 
June 7, 2022. 
 
You asked the Plan to pay for procedure code 99100 and 99140. You say that this should be paid for. The Plan 
denied your request. The Plan says procedure code 99100 and 99140 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99100 and 99140 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99100 and 99140 billed for date of service June 
7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services provided on May 20, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered.  
 
In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 28119, 
28035, and 20552. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these services. 
This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be 
paid. Based upon this information, we find that the Medicare coverage criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for the assistant at surgery services provided on May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic lab services provided on May 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that there is no other inpatient claim billed close to this 
date of service. The Plan denied your request. The Plan says these outpatient services should be included in the 
inpatient claim. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient diagnostic services provided by the 
admitting hospital, within 3 days prior to an inpatient admission, should be included in the inpatient billing.  
 
In this case, codes C9803 and 87635 are diagnostic laboratory services that were provided by the admitting 
hospital. The record shows the enrollee was an inpatient from May 17, 2022, to May 23, 2022. The services were provided within 3 days prior to admission. Therefore, they are not separately payable as outpatient 
services. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for diagnostic lab services provided on May 
15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facet joint injection provided on July 12, 2022. 
 
You asked the Plan to pay for the facet joint injection. You say that the facet joint injection was medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injection does not meet the 
Medicare LCD coverage criteria. 
 The Plan follows Medicare rules. 
 
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 facet joint injection. Our reviewer says 
that the facet joint injection is not medically necessary. Our physician reviewer found that in this case, there is 
documentation of radiculopathy. In addition, one to two levels, either unilateral or bilateral, are allowed per 
session per spine region. The need for a three or four-level procedure bilaterally may be considered under 
unique circumstances and with sufficient documentation of medical necessity on appeal. The review has 
determined that the requested facet joint injection does not meet the Medicare LCD coverage criteria. 
 
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 facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pay for a facet joint injection provided on July 12, 2022.