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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from acute rehab to optimize 
their level of functioning prior to returning home. The Plan denied your request. The Plan says the IRF 
admission is not supported based on the records received. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (81227, 81230) provided on July 13, 
2022. 
 
You asked the Plan to pay for the genetic testing. You say that this claim should be covered. The Plan denied 
your request. The Plan says this testing should be billed under a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one CPT code must be submitted for the panel. 
 
We looked at the file and Medicare rules. In this case, multiple unbundled CPT codes were billed for a genetic 
testing panel. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing (81227, 
81230) provided on July 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93325, 93321, and 93308 billed for date of 
service August 18, 2022. 
 You asked the Plan to pay for procedure codes 93325, 93321, and 93308. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 93325, 93321, and 93308 is 
bundled into payment for code 33361. 
 
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 codes 
93325, 93321, and 93308 is a column II code to column I code 33361. 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 codes 93325, 93321, and 93308 
billed for date of service August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography (93458). 
 
You asked the Plan to pre-approve a catheter placement in coronary artery(s) for coronary angiography. You 
say that you have calcium buildup in your arteries, and you get chest pains when you walk. You also say that 
you need to appeal this service because if the blockage reaches 75%, you might need stents put in. The Plan 
denied your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 a catheter placement in coronary 
artery(s) for coronary angiography. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the documentation does not support the 
rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this 
setting. Our reviewer also found that at this time cardiac catheterization would not be considered medically 
appropriate and necessary in your clinical management. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a catheter placement in coronary artery(s) for coronary angiography have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a catheter placement in coronary 
artery(s) for coronary angiography (93458).
Appeal type: Drugs
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. The Plan denied your request. The Plan says the 
submitted chart notes indicate the enrollee is only on Janumet, and there is no indication they are using insulin. 
The Plan also says a CGM is not covered for an enrollee who is not on insulin. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 30, 2021, 
to December 29, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
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 provided from November 30, 2021, to 
December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0673, E0675) provided on 
April 11, 2022. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The items at issue in this appeal were for use outside of the home. Although these items may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home.  
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0673, E0675) 
provided on April 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick (C9399). 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that the enrollee is unable to take statins due to 
muscle pains. The Plan denied your request. The Plan says Repatha Sureclick is a self-administered drug, and 
is not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick (C9399).  
 
  Benefits for Repatha Sureclick 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74150-26 billed for date of service August 
30, 2022. 
 You asked the Plan to pay for procedure code 74150-26. You say that this claim was denied in error. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 74150-26 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 74150-26 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 74150-26 billed for date of service August 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 Injectafer. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Injectafer. Our physician reviewer found there is no 
provided documentation of a trial and failure of the Plan's preferred drugs, Infed and Venofer. Our reviewer 
also found that the documentation does not support that Infed and Venofer would likely be less effective, 
and/or would likely have adverse effects for the enrollee 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2022, to October 7, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2022, to October 7, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6196 and A6219 billed for date of service 
August 19, 2022. 
 
You asked the Plan to pay for procedure code A6196 and A6219. You say that there were not routine supplies 
that are covered under room and board and were supplied on a separate date of service from the procedure 
billed. The Plan denied your request. The Plan says procedure code A6196 and A6219 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code A6196 and A6219 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code A6196 and A6219 is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of procedure code A6196 and A6219 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes A6196 and A6219 billed for date of service 
August 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the enrollee was admitted with sepsis secondary in the setting of 
small bowel obstruction and intraperitoneal abscess. The record indicates that the enrollee is improving but still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that are not currently being provided but that would be available at the LTACH facility. The elements 
of the coverage rules are not satisfied. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63048 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for procedure code 63048. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 63048 is bundled into payment for code 22633.  
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 63048 
is a column II code to column I code 22633. 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 63048 billed for date of service September 20, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacements (TAVRs) with 
prosthetic valves (codes 33362 and 33368) and transesophageal echocardiography (TEE) (93355), with an 
associated inpatient admission. 
 
You asked the Plan to pre-approve TAVRs and TEE with an associated inpatient admission. The Plan denied 
your request. The Plan says the requested services do not meet the requirements for approval. 
 
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 TAVRs and TEE with an associated 
inpatient admission. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found guidelines would not support aortic valve 
replacement based on the submitted medical records. Our reviewer also found that at this time the requested 
TAVR would not be considered medically necessary in this patient's clinical management based on the 
submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TAVRs and TEE with an associated inpatient admission have not been met. 
Specifically, the associated inpatient admission does not meet the criteria for coverage because the TAVRs and 
TEE are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve 
transcatheter aortic valve replacements (TAVRs) with prosthetic valves (codes 33362 and 33368) and 
transesophageal echocardiography (TEE) (93355), with an associated inpatient admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that without non-invasive ventilation therapy, 
the enrollee is at high risk for hospital readmission and potentially life-threatening exacerbations. The Plan 
denied your request. The Plan says the enrollee does not appear to have the severity of illness that would justify 
the need for a home mechanical ventilator. The Plan also says there is no documentation to suggest a bilevel 
positive airway pressure (BiPAP) with backup rate and average volume-assured pressure support (AVAPS) 
was utilized and failed that would otherwise necessitate the use of a home mechanical ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 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 a home ventilator. Our reviewer says 
that a home ventilator is not reasonable and necessary for the enrollee. Our physician reviewer found this 
enrollee was recently admitted after a fall, and was found to have gastrointestinal bleeding secondary to 
esophageal varices, cirrhosis of the liver with ascites, exacerbation of heart failure with preserved ejection 
fraction, and obesity-hypoventilation syndrome. Arterial blood gases were consistent with chronic hypercarbic 
respiratory failure. Our reviewer found there is no diagnosis of COPD, thoracic restrictive disease, or 
neuromuscular disease. The enrollee may benefit from BiPAP during sleep as an outpatient. Our reviewer 
found the records do not show that this has been tried and failed as an outpatient. Our physician reviewer also 
found that Medicare does not cover a home ventilator when used as BiPAP, or in the treatment of obesity 
hypoventilation syndrome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76815 billed for date of service August 12, 
2022. 
 
You asked the Plan to pay for procedure code 76815. The Plan denied your request. The Plan says payment for 
code 76815 is bundled into payment for code 76828.  
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 76815 
is a column II code to column I code 76828. 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 76815 billed for date of service August 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (76642) provided on October 10, 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 76642 is not supported in the medical record. Specifically, code 76642 is 
assigned a bilateral surgery indicator of 1. This means that a bilateral diagnostic procedure should be reported 
with 1 unit of service and modifier 50 on 1 claim line, or 1 unit of service with modifier RT on 1 claim line plus 1 unit of service and modifier LT on a second claim line. Neither claim line in this case was billed with 
modifier 50 as required by 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 the 
services (76642) provided on October 10, 2022.