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

 
We decided that the Plan has to pay for the initial hospital care (99222) provided on January 6, 2021. 
 
You asked the Plan to pay for the initial hospital care (99222). You say that the charge is supported, and this 
claim does not bundle with any other charges on this date of service. You say that the medical records support 
the billing, and the claim should be reconsidered for additional payment. The Plan denied your request. The 
Plan says that this code is not separately payable according to mutually exclusive edits. 
 
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 says that the code is not separately payable according to mutually 
exclusive edits. The Plan has not submitted documentation supporting that another code was billed on this date 
of service for CPT code 99222 to be considered inclusive. In addition, the Plan has not forwarded additional 
rationale as to why this code was denied. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the initial hospital care (99222) provided on January 6, 2021.  
 
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: Favorable

 
We decided that the Plan has to pay for the computed tomographic angiography (CTA) of the abdomen and 
pelvis (74174) and chest (71275), provided on September 29, 2021. 
 
You asked the Plan to pay for the CTA of the pelvis, abdomen and chest. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service 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 pay for the CTA of the pelvis, abdomen and chest. 
Our reviewer says that the service is medically necessary. Our physician reviewer found the necessity of 
evaluating the aortic vasculature after stent placement into not only the aorta but also the main vascular 
branches is very reasonable and standard practice to establish patency and lack of endovascular leaks. 
 
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 CTA of the pelvis, abdomen and chest have been met. Therefore, we 
decided that the Plan has to pay for the computed tomographic angiography (CTA) of the abdomen and pelvis 
(74174) and chest (71275), provided on September 29, 2021.  
 
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: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 5, 2021, to June 9, 
2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services should be covered. The 
Plan denied your request. The Plan says that the inpatient admission 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record shows 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from June 5, 2021, to June 9, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral lumbar facet joint injections 
 
You asked the Plan to pre-approve the facet joint injections. You say that you are appealing the denial for 
bilateral lumbar facet joint injections because you feel that it is medically necessary based on spondylosis 
without myelopathy or radiculopathy in the lumbosacral region. The Plan denied your request. The Plan says 
the documentation provided did not support the requested service is medically necessary. 
 
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 facet joint injections. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the LCD criteria specifies 80% pain relief after a diagnostic block. This was not 
achieved, and the test should be interpreted as NEGATIVE. Therefore, the request is deemed 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 the facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral lumbar facet joint injections
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on December 15, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this claim was not billed with an appropriate primary 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, this claim was not billed with an appropriate 
primary diagnosis code. Diagnosis code I21.A1 includes a code first note which means that the underlying 
condition must be sequenced first. Therefore, we decided that the Plan does not have to pay for the office visit 
(99215) provided on December 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy (36471). 
 
You asked the Plan to pre-approve sclerotherapy. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says the service at issue is not medically necessary. 
 
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 sclerotherapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found he record indicates that the enrollee has undergone some type of varicose procedure but still has 
reflux in the right saphenofemoral junction.  Duplex does not indicate the presence of varicosities greater than 
4 mm on the left. The record does not indicate the failure of conservative compressive treatments. The record 
does not indicate the targets planned for ablation. The record provided does not establish the medical necessity 
and reasonableness, as defined by Medicare rules, of the requested service. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy (36471).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist x-ray (73100) provided on September 20, 2021. 
 
You asked the Plan to pay for the wrist x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 73100 and 73110. 
 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 73100 
is a column II code to column I code 73110. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the wrist x-ray (73100) provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided July 16, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the limited oral exam and intraoral x-ray. You say that the provider is now 
participating so you would like the services reconsidered. The Plan denied your request. The Plan says the 
services are not covered because they were provided OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the limited 
oral exam and intraoral x-ray when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. In this case the provider was out-of-network at the time the services were rendered. Based on this information, we decided that the Plan's rules for coverage of the limited oral exam 
and intraoral x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the limited 
oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided 
July 16, 2021, by an out-of-network (OON) provider.  
 
Non-contract provider appeals require a Waiver of Liability form indicating that the enrollee is not being held 
responsible for the items or services at issue. In this case, you signed and completed a Waiver of Liability form, 
indicating that you are a non-contract provider. 
 
You claim that you are a contract provider with the Plan. Contract providers do not have appeal rights through 
the Independent Review Entity (IRE) process. If you are indeed a contract provider with the Plan, you will 
need to contact the Plan directly regarding any appeal processes that they have for contract providers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity injections (J3111). 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee will benefit from an anabolic treatment 
with Evenity injections. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drugs, Prolia or Reclast. 
 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 Evenity. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative, specifically Prolia. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred 
step one alternatives. 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity injections (J3111).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that you would like Aranesp to be covered for the 
enrollee. The Plan denied your request. The Plan says that the clinical information does not meet the 
requirement of a medically accepted FDA indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and 
Drug Administration (FDA) approved drugs if they are medically accepted as safe and effective or appropriate 
for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that 
Aranesp is safe and effective and otherwise reasonable and necessary for this enrollee. Our physician reviewer 
found due to limited options (poor surgical candidate) the use of erythropoietin such as with Aranesp is 
supported by the medical literature to avoid blood transfusions in this rare condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have been met. Therefore, we decided that the Plan has to pre-approve 
Aranesp (J0881).  
 
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 Durolane injections (J7318). 
 
You asked the Plan to pre-approve Durolane injections. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy will be considered 
medically reasonable and necessary when the patient has failed at least three months of conservative therapy 
and either aspiration of the knee or intra-articular corticosteroid injection therapy. Viscosupplementation is 
considered not medically reasonable and necessary and will not be covered when a repeat series of injections is 
initiated prior to six months after completion of the previous course of treatment. 
 
We looked at the file and Medicare rules. The records do not contain documentation of previous conservative 
therapy. The records also document that the enrollee previously received viscosupplementation therapy, less 
than six months prior to this request. Based on this information, we decided that Medicare rules for coverage of 
Durolane injections have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Durolane injections (J7318).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filter (A7038, A7039), and other medicine services 
(99199), provided on October 16, 2021, through November 9, 2021, by a provider not certified with Medicare. 
 
You asked the Plan to pay for the continuous positive airway pressure (CPAP) supplies. You say that the items 
should be covered. The Plan denied your request. The Plan says you obtained these items through a provider 
who is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the filter (A7038, A7039), and other 
medicine services (99199), provided on October 16, 2021, through November 9, 2021, by a provider not 
certified with Medicare.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services rendered on July 
18, 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 submitted records do not support the billing of procedure code 99285. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is Level 5 emergency department visit for 
evaluation and management of patient with problem immediately threatening life, including comprehensive 
history and physical examination, and medical decision-making of high complexity. 
 
We asked our 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 submitted 
records do not support the billing of procedure code 99285. Our reviewer found the enrollee presented to the ED on July 18, 2020 with a foreign body found in the esophagus. She gave a history of eating ribs and felt the 
food was "stuck." She was evaluated and gastroenterology was consulted. The records do not contain 
documentation of high complexity medical decision making; therefore, code 99285 is not supported. 
 
We looked at this reviewer'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 pay for the emergency department (ED) services rendered on July 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that you don't want to try alternative medicine and 
want to avoid surgery. You say that this injection is medically necessary and will prevent surgery. The Plan 
denied your request. The Plan says use of Synvisc-one requires you to try other medicines 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 Synvisc-One. Our reviewer says that 
the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found that the provided records do not indicate that you have tried and failed the Plan's 
preferred step one alternative. The record does not indicate that you have a contraindication to or would have 
an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.