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

 
We decided that the Plan has to pre-approve an epidural steroid injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says that  an imaging study showing narrowing of the spine due to a ruptured spine disc, 
bone spur, and/or severe wear and tear on the discs in the spine is needed for this request. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 pre-approve the injection. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that a computed tomography (CT) scan shows progression of the disc disease and facet disease. 
Therefore, the request is medically 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 injection have been met. Therefore, we decided that the Plan has to pre-
approve an epidural steroid injection 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair (PWC). 
 
You asked the Plan to pre-approve the PWC. You say that you are unable to get in and out of your home which 
has led to falls. Your current wheelchair is too big to fit through the door. The Plan denied your request. The 
Plan says your needs can be met with a power scooter, which has been approved. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 PWC. Our reviewer says that the 
requested PWC is not considered reasonable and necessary. Our physician reviewer found he documentation 
indicates that the patient has a mobility limitation that significantly impairs her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. The documentation does not support that the patient's mobility limitation cannot be sufficiently resolved by the use of an appropriately manual wheelchair as there is no 
objective detailed musculoskeletal or neuromuscular exam of the bilateral upper extremities indicating deficits. 
The records also indicate that a power scooter could meet her needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PWC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Group 2 heavy duty power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 17, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 17, 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 IRF care is medically necessary and should be 
approved. The Plan denied your request. The Plan says the records do not support that IRF criteria are met. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician and nursing oversight in an IRF. The 10/7/22 progress note 
indicates the patient's diarrhea was still being managed and worked up. While the patient may benefit from 
additional multiple therapies, including physical and occupational therapy, the documentation does not reveal 
that the patient's functional level or endurance requires this therapy or can tolerate it on an intensive IRF level. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70544 is bundled into 
payment for code 70551. 
 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 70551. 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 70544 billed for date of service March 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services (procedure codes 75726 and 75774) 
provided to the enrollee on March 17, 2022. 
 
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 the denied codes cannot be verified. 
 
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 the denied codes is: 
 
CPT 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
 
 CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that Medicare specifically prohibits 
the billing for angiography separate from the embolization procedure and considers such angiography 
roadmapping s part of the billed and paid embolization procedure CPT 37244. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for angiography services (procedure codes 75726 and 75774) provided to the enrollee on March 
17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 
8, 2021, to July 14, 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 the paid DRG 308 was incorrectly coded, and should have been DRG 309.  
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 DRG 308 (CARDIAC ARRHYTHMIA AND 
CONDUCTION DISORDERS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found that acute kidney failure was stated to be secondary to ventricular tachycardia. 
Further diagnostics were undertaken to evaluate acute renal failure, but these diagnostics did not include 
specific workup for acute tubular necrosis, nor could a physician rationale for the diagnosis of acute tubular 
necrosis (ATN) be found. The review has determined that DRG 309: CARDIAC ARRHYTHMIA AND 
CONDUCTION DISORDERS WITH CC is supported. The records do not support the use of secondary 
diagnosis code N17.0 - acute kidney failure with tubular necrosis.  
 
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 inpatient hospital services provided to the enrollee from July 8, 2021, to July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0416 billed for date of service December 1, 
2021. 
 
You asked the Plan to pay for procedure code G0416. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code G0416 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0416 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0416 billed for date of service December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76380 billed for date of service March 18, 
2021. 
 
You asked the Plan to pay for procedure code 76380. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says payment for code 76380 is bundled into payment for code 78803. 
 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 76380 
is a column II code to column I code 78803. 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 76380 billed for date of service March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for  a pneumatic compressor, segmental home model without calibrated 
gradient pressure (E0651) provided February 1, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that it is your belief that this enrollee 
meets the policy requirements for the equipment prescribed by their physician. The Plan denied your request. 
The Plan says that services exceed the recommended frequency. 
 
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 not substantiated their reason to continue to deny. The Plan has not 
provided any documentation to specify in which way the services was exceeded whether if this was a duplicate 
claim, the number of units or if the services exceeded the authorization that may have been on file. Therefore, 
we decided that the Plan has to pay for  a pneumatic compressor, segmental home model without calibrated 
gradient pressure (E0651) provided February 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 11, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic testing must be billed with 
the DEX-Z code.  
We looked at the file and Medicare rules. The file shows that the services were not billed with the required 
DEX_Z code. 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 laboratory services rendered on 
April 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hizentra intravenous immune globulin (IVIG) 
treatments. 
 
You asked the Plan to pre-approve the IVIG treatments. You say that it is felt that this treatment is needed. The 
Plan denied your request. The Plan says this is not a covered indication for Hizentra. 
 
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 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 IVIG treatments. Our reviewer says 
that the requested treatments are not considered medically necessary. Our physician reviewer found based on 
the medical records provided and the Medicare-approved major drug compendia, there is no documentation 
that the Hizentra at issue in this case meets all Medicare criteria for medically reasonable and necessary for the 
patient. Nonfamilial hypogammaglobulinemia and lung transplant status are not medically accepted indications 
for use of Hizentra according to the Medicare-approved major drug compendia.  
 
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 IVIG treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hizentra intravenous immune globulin (IVIG) treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit rendered on February 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99204 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the file shows that the 
enrollee was seen by a physician in the same practice on March 18, 2021; therefore, a new patient office visit 
does not apply. 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 new patient office visit rendered 
on February 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services provided on June 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for transitional care management services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network, and it 
was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for transitional care management services provided on 
June 17, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group 
(DRG) 871 provided from December 22, 2021, to December 25, 2021. 
 You asked the Plan to pay for the inpatient hospital services with DRG 871. You say that the medical records 
support the billing of the principal diagnosis code A41.9 for sepsis with DRG 871. The Plan denied your 
request. The Plan says the medical records do not support the billing of the principal diagnosis code A41.9 for 
sepsis with DRG 871. 
 
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 principal diagnosis code A41.9. 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 with DRG 871. Our reviewer 
says that the medical records do not support the billing of the principal diagnosis code A41.9 for sepsis with 
DRG 871. Our physician reviewer found based on the documentation provided, the enrollee was hospitalized 
with myalgias. She was treated for chronic obstructive pulmonary disease (COPD) and congestive heart failure 
(CHF), in the setting of morbid obesity. There is no evidence that the enrollee had sepsis or an infection. As 
such, the billing of sepsis (A41.9) is not warranted.  
 
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 with diagnosis related group (DRG) 871 provided from December 22, 2021, 
to December 25, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visits provided from February 17, 2021, 
through November 1, 2021. 
 
You asked the Plan to pay for the mental health visits. You say that each visit is substantiated in the original 
claim, and you are requesting reimbursement. The Plan denied your request. The Plan says the services 
provided from February 17, 2021, through April 8, 2021, were not filed timely. The Plan also says the 
remaining visits denied as authorization for out-of-network services was not received. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The rules also say that plans can require 
enrollees to get care from network providers. 
 
The record shows that a claim for the mental health visits provided from February 17, 2021, through April 8, 
2021, was not filed until May 6, 2022. This means that more than one calendar year from the date of service 
had passed before a claim was filed. Claims filed later than one calendar year after the date of service will not 
be paid. 
  In addition, the provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for the mental health visits 
provided from June 15, 2021, through November 1, 2021.Therefore, we decided that the Plan does not have to 
pay for the mental health visits provided from February 17, 2021, through November 1, 2021.