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 May 27, 2022, through 
June 1, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the claim should be paid. The Plan 
denied your request. The Plan says that the stay is 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found 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 emergency 
department (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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from May 27, 2022, through June 1, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on February 5, 2022, to 
March 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services rendered on February 5, 2022, to March 
6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75726 and 75774 billed for services 
provided on July 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that the service is coded appropriately. The Plan 
denied your request. The Plan says the services are inclusive to the main procedure. 
 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 75726 is angiography, visceral, selective or 
supraselective (with or without flush aortogram), radiological supervision and interpretation. The definition of 
code 75744 is Angiography, selective, each additional vessel studied after basic examination, radiological 
supervision and interpretation (List separately in addition to code for primary procedure). 
 
We find that CPT codes 75726 and 75744 are included in the primary vascular procedure. Providers must not 
unbundle services, but bill with the most comprehensive code that describes the services provided. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 75726 and 75774 billed for 
services provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodontist visit to be rendered by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you do not wish to be seen by either of the 
two groups in your area. You also say that your general dentist suggested that you see this out-of-network 
provider. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by your supplemental benefits. 
 
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. 
 
 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
periodontist visit to be rendered by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service September 9, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70553. 
 
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 70544 is a column II code to column I code 70553. The code at issue 
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 
70544 billed for date of service September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGM.  
You asked the Plan to pay for the CGM. You say that the enrollee would like to have a CGM instead of a home 
blood glucose monitor. The Plan denied your request. The Plan says there was insufficient information 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the CGM have been met. 
Documentation was not provided to verify if the enrollee meets the Medicare criteria. Therefore, we decided 
that the Plan does not have to pay for the CGM.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
30, 2022. 
 
You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (G0481) provided on July 6, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this is the only claim submitted by this lab for 
this enrollee; there are no other services which could be bundled with this claim. The Plan denied your request. 
The Plan says the enrollee was in a Part A covered Skilled Nursing Facility (SNF) stay at the time of services; 
therefore, the payment for these laboratory services is bundled into the facility payment to the SNF and are not 
separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that laboratory tests performed for an SNF's Medicare 
inpatients covered under Part A are included in the Prospective Payment System (PPS) SNF payment. 
 
We looked at the file and Medicare rules. The record shows that the enrollee was in a Part A covered SNF stay 
at the time of services. Based on this information, we decided that Medicare rules for coverage of laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
(G0481) provided on July 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting approval for inpatient 
rehabilitation services for the enrollee. In your medical opinion, this enrollee has rehabilitation needs to 
improve strength, endurance, activities of daily living (ADLs), and mobility as well as medical needs that 
necessitates the daily medical oversight provided on our unit. The enrollee is motivated to improve and will 
tolerate the three hours of therapy required of acute rehabilitation. The Plan denied your request. The Plan says 
based on the clinical information provided, the enrollee is limited from a recent surgery and the therapy needs 
are not complex in nature and can be provided safely at a lower level of care: the enrollee does not require 
more than one intensive therapy at least three hours per day, five days per week as these conditions have led 
physical limitations that are not specialized. Therefore, the request to overturn the denial of acute rehabilitation 
admission is not granted. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided safely in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyvanse. 
 
You asked the Plan to pre-approve Vyvanse. You say that the enrollee has continually shown better 
organization and concentration on Vyvanse. You also say that it is in your medical opinion that the enrollee 
would benefit with Vyvanse. The Plan denied your request. The Plan says Vyvanse is a self-administered drug 
and does not fall under Part B coverage. 
 
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 Vyvanse.  
 
  Benefits for Vyvanse 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy administration services coded 96401 
provided on June 7, 2022. 
 
You asked the Plan to pay for the chemotherapy administration services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed 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 96401 is chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic. 
 
 
 We find that CPT code 96401 is not supported in the medical record. Specifically, the medical records indicate 
that therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular was performed. This 
means there is a more appropriate code to be billed for the services rendered. Based on this information, we 
decided that Medicare rules for coverage of the chemotherapy administration services have not been met. 
Therefore, we decided that the Plan does not have to pay for the chemotherapy administration services coded 
96401 provided on June 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferric Carboxymaltose (J1439). 
 
You asked the Plan to pre-approve Ferric Carboxymaltose. The Plan denied your request. The Plan says the 
enrollee does not meet the guideline requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for 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 Ferric Carboxymaltose. Our reviewer 
says that the enrollee does not meet the criteria for coverage for Ferric Carboxymaltose. Our physician 
reviewer found the record indicates that the enrollee has a reported diagnosis of iron deficiency anemia. The 
record provided does not document iron deficiency or an intolerance to oral iron.  Our reviewer found that the 
FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and the 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ferric Carboxymaltose have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Ferric Carboxymaltose (J1439).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 12, 
2022. 
 
You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 2, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. 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 June 30, 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 office visit have not been met. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on February 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular junction testing provided on October 25, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuromuscular junction testing is coverage for the 
indications established in the applicable LCD. 
 
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 testing is not medically reasonable and necessary. Our physician reviewer found that train of four 
testing was performed as part of the intraoperative monitoring evaluation. The testing was not done "to 
diagnose patients with fatigable weakness who are being evaluated for possible disease of the neuromuscular junction". Nor was such a diagnosis/condition that is generally evaluated with this type of testing present in this 
case. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pay for the neuromuscular junction testing provided on October 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0427, A0425) provided on June 
30, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
were reported correctly. The Plan denied your request. The Plan says this claim is missing one of the necessary 
secondary diagnosis codes as directed by the Local Coverage Determination. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that ambulance transportation must be reported with a secondary diagnosis code from the following 
list: Z74.01 (Bed confinement status), Z74.3 (Need for continuous supervision), Z78.1 (Physical restraint 
status) and Z99.89 (Dependence on other enabling machines and devices). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, this claim was not billed with one of the listed diagnosis codes as a secondary diagnosis. Therefore, we decided that the Plan does not have to pay for 
ambulance transportation (A0427, A0425) provided on June 30, 2022.