Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for moderate sedation services (procedure code 99152, 99153) provided to 
the enrollee on December 8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that this is an unbundled service. 
 
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 has provided an inadequate case file in this instance. The plan has not 
provided enough information about their denial. The plan has not specified what codes the denied codes are not 
able to be unbundled from. Additionally, the plan provided a case narrative for a different enrollee in the case 
file. Therefore, we decided that the Plan has to pay for moderate sedation services (procedure code 99152, 
99153) provided to the enrollee on December 8, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided on April 
20, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that your provider ordered this 
test, and therefore, should be responsible for this copayment. Not you. The Plan denied your request. The Plan 
says the copayment that was applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for other outpatient diagnostic tests - radiological diagnostic services, not including x-rays.  
 
You have been asked to pay a $110 copayment for a diagnostic ultrasound. A diagnostic ultrasound 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. Therefore, we decided that the Plan 
does not have to waive the copayment for a diagnostic ultrasound provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection rendered on March 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that payment may not be made by carriers for codes with a 
PC/TC indicator of 5 when they are provided to hospital inpatients or patients in a hospital outpatient 
department. 
 
We looked at the file and Medicare rules. Billed procedure code 96374 has a PC/TC indicator of 5 and was 
billed to a hospital outpatient. Therefore, we decided that the Plan does not have to pay for the injection 
rendered on March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (85060) provided April 14, 2022. 
 
You asked the Plan to pay for the pathology services. 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 85060 is not supported in the medical record. Specifically, the service has a 
professional component / technical component indicator of 8 and the service was performed in the inpatient 
setting. The service is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay 
for pathology services (85060) provided April 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 12, 
2022. 
 
You asked the Plan to pay for procedure code 99285. You say that this service was billed correctly. The Plan 
denied your request. The Plan says the medical records did not support the billing of code 99285. The Plan 
contends that the appropriate code for the level of complexity should have been 99283. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 procedure code 99285 Our reviewer says 
that procedure code 99285 is not supported in the medical record. Our reviewer found the enrollee was 
evaluated in the emergency room on January 12, 2022, for a sore throat and was diagnosed with tonsillitis. She 
was treated with IV Decadron, IV Rocephin, and IV Toadol. She was discharged home later the same day. The 
review indicates that medical decision making was not of high complexity and the presenting problem(s)  were 
not of high severity and posed an immediate significant threat to life or physiologic function. Code 99285 was 
not supported in the medical record, and the Plan was justified in downgrading the code to 99283 based on the 
complexity of the patient's 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 procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 billed for date of service January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abutment Supported Porcelain/Ceramic Crown 
(D6058) and Custom Fabricated Abutment (D6057) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these procedures are being requested on a 
medical basis. The Plan denied your request. The Plan says that these services are not covered. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
Abutment Supported Porcelain/Ceramic Crown (D6058) and Custom Fabricated Abutment (D6057) for the 
enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve radiofrequency endovenous ablation therapy (36475). 
 
You asked the Plan to pre-approve radiofrequency endovenous ablation therapy. You say that the requested 
treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says that medical-
necessity rules for the requested treatment have not been met., 
 
The Plan follows Medicare rules. The rules say that treatment of varicose veins of the lower extremities is 
medically necessary and reasonable as follows when the criteria listed in the Medicare rules section of this 
letter are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency endovenous ablation 
therapy. Our reviewer says that the requested treatment is medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is documented to have a persistent ulcer despite endovenous 
interventions. The enrollee's most recent duplex scan demonstrates no evidence of deep vein thrombosis. The 
scan does demonstrate significant insufficiency in a lateral perforator vein that was documented to be 
associated with the lateral ulcer. There is documentation of good distal pulses. There is satisfactory 
documentation of efforts at conservative therapy including the use of an Unnas boot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency endovenous ablation therapy have been met. Therefore, we 
decided that the Plan has to pre-approve radiofrequency endovenous ablation therapy (36475).  
 
  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: Favorable

 
We decided that the Plan has to pre-approve radiopharmaceutical therapy, by intra-arterial particulate 
administration (79445) and special treatment procedure (77470) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that there is not enough evidence that this is useful for the 
enrollee's condition. 
 
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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The patient has 
metastatic disease but whether or not it is minimal extrahepatic disease is subjective. An August 5, 2022, 
PET/CT showed extensive disease in the liver with what is described as multiple, bilateral lung metastases, all 
less than 1 cm. No other sites of disease were noted. The patient is also undecided on systemic therapy. Sub-cm 
lung lesions could qualify as minimal disease in the setting of much more life-threatening liver involvement for 
which control could improve quality and duration of life. It is notable that the NCCN guidelines state that liver 
directed therapies are preferred over systemic therapy for unresectable disease and appropriate for patients with 
minimal extraphepatic metastatic disease. In general, every effort to maintain tumor control using liver 
directed therapies can be considered appropriate and within accepted standards of medical practice. 
 Our physician reviewer found that the enrollee's condition does meet criteria for coverage of these services. 
 
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 pre-
approve radiopharmaceutical therapy, by intra-arterial particulate administration (79445) and special treatment 
procedure (77470) for the enrollee.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88341, 88342, 88360) provided November 23, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the codes billed are 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 CPT code. 
 
 
 
 
 
 We find that CPT code 88341, 88342, & 88360 is not supported in the medical record. Specifically, this service 
has a professional component / technical component of 1. The service was provided in an outpatient facility 
and was billed with place of service 22. 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 lab services 
(88341, 88342, 88360) provided November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (88305) provided on January 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 payment for CPT code 88305 is not supported in the medical record. Specifically, this code has a 
PC/TC indicator of 1. The services were billed with place of service. As such, the professional interpretation 
must be billed with modifier -26 for payment to be considered. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (88305) provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve irreversible electroporation (NanoKnife procedure). 
 
You asked the Plan to pre-approve irreversible electroporation. You say that you are appealing this supporting 
records. The Plan denied your request. The Plan says this procedure is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve irreversible electroporation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found irreversible electroporation has low morbidity, but suboptimal 
intermediate-term outcomes compared with conventional thermal ablation techniques for small low-complexity 
tumors. Longer-term imaging and clinical follow-up are required to validate this procedure in the treatment of 
renal cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of irreversible electroporation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve irreversible electroporation (NanoKnife procedure).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that you need this because your current 
method damages your fingers. 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 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 documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex (immune globulin) injection. 
 
You asked the Plan to pre-approve Gamunex injection. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says no medical records were provided to support the necessity of this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We looked at the file and Medicare rules. Review of the file shows that no medical records were provided to 
the Plan to support the necessity of the requested drug. The Plan had made multiple attempts to obtain medical 
records in order to consider this request without response. This means there is no documentation provided to 
support medical necessity of the requested drug. Based on this information, we decided that Medicare rules for 
coverage of Gamunex injection have not been met. Therefore, we decided that the Plan does not have to pre-
approve Gamunex (immune globulin) injection.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the DecisionDx testing provided on December 30, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this is not medically 
necessary. 
 
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 pay for the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that peer-reviewed publications have demonstrated that DecisionDx-SCC is an independent predictor of 
metastatic risk and that integrating DecisionDx-SCC with current prognostic methods can add positive 
predictive value to clinician decisions regarding staging and management. DecisionDx-SCC demonstrates a 
high degree of analytical precision, yielding high concordance rates across multiple performance experiments, 
along with exhibiting robust technical reliability on clinical samples. The requested DecisionDx testing is 
medically reasonable and 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 testing have been met. Therefore, we decided that the Plan has to pay for the 
DecisionDx testing provided on December 30, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records do not show that the enrollee had a cryptogenic stroke nor 
event monitor is contraindicated and/or unrevealing. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient has no 
history of atrial fibrillation. A recent randomized clinical trial found that continuous monitoring for atrial 
fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) was 
not superior to usual care in reducing stroke or systemic embolism among patients at high risk of stroke but 
without a known prior history of atrial fibrillation. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR) for the enrollee.