Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on September 
13, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered on 
September 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 22, 2021, 
to September 29, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
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 diagnosis codes J96.22 and J96.21. 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 at the DRG originally billed. 
Our reviewer says that the submitted records do not support the billing of diagnosis codes J96.22 and J96.21. 
Our physician reviewer found the enrollee has a history of chronic obstructive pulmonary disease (COPD) and 
asthma and was oxygenated sub-optimally with saturations in the low 90s on room air. It was deemed 
worthwhile to bring her oxygenation to a more satisfactory level and a few liters of oxygen were employed to 
do that until after some days in hospital she was oxygenating normally on room air. There is no mention of her 
having needed home oxygen, so evidence for chronic hypoxic respiratory failure is absent. She was not in 
intense respiratory distress, was not tachypneic nor struggling. The one blood gas that appears suggests the 
presence of chronic compensated respiratory acidosis but does not support acute hypercapnic respiratory 
failure.  
 
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 on September 22, 2021, to September 29, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
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 the services are necessary for you to improve quality 
of life. The Plan denied your request. The Plan says your current needs can be met in a skilled nursing facility. 
 
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 clinical documentation shows that you have functional impairments and chronic 
comorbidities however no active functional or clinical issues are specified. Medical and rehabilitation needs 
would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22554, 22808, and 63081 billed for date of 
service June 15, 2022 
 
You asked the Plan to pay for the billed services. You say that the services were paid for the primary surgeon. 
The Plan denied your request. The Plan says the codes 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 22554 is arthrodesis, anterior interbody technique, 
including minimal discectomy to prepare interspace (other than for decompression); cervical below C2. The  
CPT Code Manual definition of code 22808 is arthrodesis, anterior, for spinal deformity, with or without cast; 
2 to 3 vertebral segments. The CPT Code Manual definition of code 63081 is vertebral corpectomy (vertebral 
body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); 
cervical, single segment. 
 
We find that CPT codes 22554, 22808, and 63081 are not supported in the medical record. The medical records 
provided do not describe the services as billed. 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 22554, 22808, and 63081 billed for date of service June 15, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on September 23, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Aranesp. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
The elements of the coverage criteria are not satisfied. 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) (62323).  
You asked the Plan to pre-approve an ESI. You say that the enrollee has low back pain that worsens with 
activity. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the three (3) requirements are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ESI. Our reviewer says that an ESI is 
not medically necessary. Our physician reviewer found the provided documentation does not support that the 
enrollee has radiculopathy. The reviewer found that there is no history, physical examination, and concordant 
radiological image-based diagnostic testing and supporting lumbar, cervical or thoracic radiculopathy, radicular 
pain and/or neurogenic claudication due to central disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis. Therefore, the reviewer found that the 
requested ESI is not medically reasonable or necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI) (62323).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 1, 2022. 
 
You asked the Plan to pay for the services. 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 services at issue were reimbursed 
by the Plan on June 28, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the ambulance services provided on May 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005 and 93041 billed for August 27, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure codes 93005 and 93041 have an OPPS status 
indicator of Q1(S) and were billed with procedure code 99285 for the same date of service. Code 99285 has an 
OPPS status indicator of V; therefore, codes 93005 and 93041 cannot be separately paid. Therefore, we decided 
that the Plan does not have to pay for procedure codes 93005 and 93041 billed for August 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service September 
30, 2022. 
 
You asked the Plan to pay for procedure code 99292. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this service is an add-on code which was billed without an 
appropriate primary procedure for the same date of service. 
 
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 99292 
is an add-on code and has not been billed with an appropriate primary procedure code. 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 99292 billed for date of service September 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft services. 
 
You asked the Plan to pre-approve allograft services. You say that the records provided support the need for the 
services which remain in dispute. The Plan denied your request. The Plan says allograft is unproven and not 
medically necessary. 
 
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 allograft services. Our reviewer says 
that allograft services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Bone Morphogenetic Protein (BMP) is not approved by the Food and Drug Administration 
(FDA) for use in the posterior spine. Iliac crest autograft bone is the gold standard and should be used 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 allograft services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve allograft services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thoracic-lumbar-sacral orthoses (TLSO), triplanar 
control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal 
junction and terminates just inferior to scapular spine (L0464). 
 
You asked the Plan to pre-approve a TLSO. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the orthosis is provided to an enrollee during an 
inpatient hospital or Part A covered SNF stay prior to the day of discharge; and the enrollee uses the item for 
medically necessary inpatient treatment or rehabilitation. A claim must not be submitted to the DME MAC in 
this situation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say payment for the requested device is included in 
the payment to a hospital or SNF. The cost of a back brace is covered as part of the cost of the surgery if it is 
used during the hospital stay. The records show that payment for the back brace is already included in the 
coverage in the enrollees hospitalization. Based on this information, we decided that Medicare rules for 
coverage of a TLSO have not been met. Therefore, we decided that the Plan does not have to pre-approve 
thoracic-lumbar-sacral orthoses (TLSO), triplanar control, modular segmented spinal system, four rigid plastic 
shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine (L0464).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Xgeva. 
 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 Xgeva. Our reviewer says that the 
enrollee does not meet the coverage criteria for Xgeva. Our physician reviewer found the case file does not 
contain documentation of trial and failure of Pamidronate or Zoledronic acid. Our reviewer also found that the 
documentation does not support that Pamidronate or Zoledronic acid 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Infed and Venofer. 
 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 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the plan's preferred drugs. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred drugs. Therefore, 
the reviewer found that the step therapy criteria have not been 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 51785, 95861, and 95870 billed for date of 
service June 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed codes are not supported in the records. 
 
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 51785 is needle electromyography studies (EMG) of anal 
or urethral sphincter, any technique. The CPT Code Manual definition of code 95861 is needle 
electromyography; 2 extremities with or without related paraspinal areas. The CPT Code Manual definition of 
code 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles 
(unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters. 
 
We find that CPT codes 51785, 95861, and 95870 are not supported in the medical record. Specifically, the 
codes at issue are not described in the records as billed. 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 51785, 95861, and 95870 billed for date of service June 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service November 3, 
2022. 
 
You asked the Plan to pay for procedure code 74018. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 74018 is bundled into 
payment for code 74250. 
 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 74018 
is a column II code to column I code 74250. 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 74018 billed for date of service November 3, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging, single-photon emission 
computerized tomography (SPECT) scan (78452). 
 
You asked the Plan to pre-approve a SPECT scan. You say that a nuclear stress test was not approved, and the 
enrollee is unable to walk on a treadmill due to osteoarthritis. You also say that the electrocardiogram shows 
sinus bradycardia, and the enrollee has a strong family history of coronary artery disease (CAD). The Plan 
denied your request. The Plan says this request is not medically necessary because the records show that the 
enrollee does not have any cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities 
on cardiac testing. 
 
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion studies performed based on the 
presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or 
abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc.) will be considered 
screening and denied as not covered by Medicare. 
 
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 SPECT scan. Our reviewer says that a 
SPECT scan is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has a family history of coronary artery disease, but has no cardiac symptoms. There is no 
documentation that the electrocardiogram (ECG) shows an uninterpretable pattern or that the enrollee is unable 
to exercise. Our reviewer found that there is no evidence provided that would support the need for radionuclide 
stress testing at this time. Our physician reviewer also found that there is insufficient documentation to support 
the medical necessity for the requested cardiac stress testing in this enrollees 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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a myocardial perfusion imaging, single-photon emission computerized tomography 
(SPECT) scan (78452).