Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the bone marrow aspiration (20939), arthrodesis (22633 and 22634), 
posterior segmental instrumentation (22842) and insertion of interbody biomechanical device (22853) provided 
on April 26, 2021. 
 
You asked the Plan to pay for the bone marrow aspiration (20939), arthrodesis (22633 and 22634), posterior 
segmental instrumentation (22842) and insertion of interbody biomechanical device (22853). You say that the 
attached operative notes support codes 20939, 22633, 22634, 22842 and 22853. The Plan denied your request. 
The Plan says that procedure codes 20939, 22633, 22634, 22842 and 22853 are not supported by the medical 
records submitted. 
 
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. Specifically, the record indicates that the Plan reviewed medical records to 
support the denial. The Plan has not forwarded any clinical information and we are unable to determine if the 
Plan was justified in denying the billed services. It is the burden of the Health Plan to substantiate their denial 
with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that 
the Plan has to pay for the bone marrow aspiration (20939), arthrodesis (22633 and 22634), posterior segmental 
instrumentation (22842) and insertion of interbody biomechanical device (22853) provided on April 26, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not 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 does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that this patient 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on October 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that the patient's doctor ordered these labs because they 
were considered medically necessary. The Plan denied your request. The Plan says that the lab services 
provided were not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the lab services by a contract provider. Specifically, the enrollee's contracted 
doctor collected a specimen from the patient and sent the specimen to your lab. As a plan provider, this 
ordering doctor is supposed to know what services are covered under the Plan. By sending this specimen to 
your lab for testing, the ordering plan provider made the determination that this service is medically necessary 
and coverable. Under Medicare rules, this means the lab services is considered approved by the plan. 
Therefore, we decided that the Plan has to pay for lab services provided on October 5, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 26, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has not been billed in accordance 
with Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on October 
11, 2021. 
 
  You asked the Plan to pay for the moderate sedation services (99153). You say that the medical claim was 
billed correctly with the correct place of service. You say that the medical records substantiate the place of 
service and payment should be reconsidered. The Plan denied your request. The Plan says CPT code 99153 
may not be paid if furnished to a hospital inpatients or patients in a hospital outpatient department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) 
provided on October 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the abdominal x-ray provided on 
October 5, 2021, billed with code 74018-26-Q6. 
 
You asked the Plan to pay for the x-ray interpretation as billed. You say that the records show that two services 
were provided. The Plan denied your request. The Plan says there is no evidence to support that two x-ray 
interpretations were performed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
In this case, the claim shows that the exact same services were billed on both. The records provided show two 
imaging reports, formatted slightly differently, but both are signed at the exact same time by the same 
physician, and both list comparison from 2019. As such, these reports do not support that this claim was not a 
duplicate. Therefore, we decided that the Plan does not have to pay for the interpretation of the abdominal x-
ray provided on October 5, 2021, billed with code 74018-26-Q6.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 19, 2021. 
 
You asked the Plan to pay for the ConfirmMDx testing. You say that this was medically necessary testing only 
available from this lab. The Plan denied your request. The Plan says criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx testing is covered when prior biopsy 
histology does not include a prior diagnosis of prostate cancer or cellular atypia suspicious for cancer. 
 
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 ConfirmMDx testing. Our reviewer says 
that the criteria for the testing provided have not been met in this case. Our physician reviewer found the 
enrollee is a male with a prostate-specific antigen level of 5.7 who underwent ultrasound-guided prostate 
biopsy on 11/19/2021. Pathology revealed atypical small acinar proliferation (ASAP) in 2 of 12 core biopsies. The coverage criteria are not met. Specifically, ConfirmMDx testing is not covered when a prior biopsy shows 
cancer or ASAP. 
 
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 ConfirmMDx testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the ConfirmMDx testing provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical/dialysis services provided outside of the United 
States from August 3, 2021, through October 7, 2021. 
 
You asked the Plan to pay for the foreign medical/dialysis services. You say that you needed these services or 
you would have died. You feel that the Plan should make this payment. The Plan denied your request. The Plan 
says itemized bills and proof of payment were requested. The claims cannot be processed without that 
information. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover most foreign medical 
services aside from the limited exceptions described. Your Plan does provide a benefit to cover these services, 
but reimbursement requires that the services be paid up front by the enrollee.  
 In this case, the file shows multiple invoices for these services; however, there is no document which shows 
that the enrollee made payment for them. The Plan's benefit only provides reimbursement when the services are 
paid for by the enrollee. Without evidence of this, we find that the Plan's rules for coverage of the foreign 
medical care have not been met. Therefore, we decided that the Plan does not have to pay for the 
medical/dialysis services provided outside of the United States from August 3, 2021, through October 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Esmella program services you received from a plan provider from 
October 20, 2021, to November 5, 2021. 
 
You asked the Plan to pay for the Esmella program. You say that these services were medically necessary 
because you became incontinent after prostate surgery. The Plan denied your request. The Plan says that the 
Esmella program is not considered medically necessary and reasonable because its long-term effectiveness has 
not been established. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the Esmella program services by a contract provider. The file does not show that the Plan 
provided notice that the Esmella program would not be covered. Under Medicare rules, this means the Esmella 
program is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the Esmella 
program services you received from a plan provider from October 20, 2021, to November 5, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prevymis for the enrollee. 
 
You asked the Plan to pre-approve Prevymis. You say that Prevymis is medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not met. 
 
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 Prevymis. Our physician reviewer found Prevymis is FDA approved in stem cell transplantation, 
not renal transplantation for CMV prophylaxis.  There is no evidence in the records that patient has failed 
therapy.  It is inferred that because this patient has lymphoctopenia and this therapy is indicted in stem cell 
bone marrow transplantation that this may be better. However, as there is no indication in the records provided 
to use this alternative therapy, Medicare coverage criteria are not met. We looked at this physician's review, the 
file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prevymis 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Prevymis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L5973 Endo skeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source, for the enrollee. 
 
You asked the Plan to pre-approve L5973 Endo skeletal ankle foot system, microprocessor-controlled feature, 
dorsiflexion and/or plantar flexion control, includes power source. You say that this accessory is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this accessory. 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 L5973 Endo skeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source. Our reviewer says that 
Medicare coverage criteria are not met. Our physician reviewer found according to Medicare additional 
features or components to a prosthesis may be necessary depending on the beneficiarys potential functional 
abilities.  Potential functional ability is based on the reasonable expectations of the prosthetist, and treating 
practitioner, considering multiple factors.  These factors include the beneficiarys past history, current 
condition including the status of the residual limb and the nature of the other medical problems and the 
beneficiarys desire to ambulate.  A level 3 ambulator has the ability or potential for ambulation with variable cadence.  Typical of the 
community ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. 
In this case, the documentation supports that the member is a K3 ambulator and the health plan has replaced the 
part of the prosthesis that is broken and delaminating.  The documentation does not support why the member 
requires a new microprocessor and advanced ankle and foot system as his current one is functional.  The 
requested replacement part is not 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 L5973 Endo skeletal ankle foot system, microprocessor-controlled feature, 
dorsiflexion and/or plantar flexion control, includes power source have not been met. Therefore, we decided 
that the Plan does not have to pre-approve L5973 Endo skeletal ankle foot system, microprocessor-controlled 
feature, dorsiflexion and/or plantar flexion control, includes power source, for the enrollee.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not 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 does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a 
hip fracture after a fall. Medical problems are stable.  There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not 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 does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for coronary artery 
bypass grafting. Medical problems are stable.  There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.