Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99232 billed for May 1, 2022, to 
May 3, 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 codes 99223 and 99232 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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
The definition of code 99232 is initial hospital inpatient or observation care, per day, for the evaluation and 
management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes 
must be met or exceeded. 
 
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 these services. Our reviewer says that procedure codes 99223 
and 99232 are not supported. Our reviewer found the records do not document a comprehensive history with 
four or more elements in the history of present illness, as required for this level of care. The records do not 
document medical decision making of high complexity that would require an extensive number of diagnoses or 
management options, an extensive amount and complexity of data reviewed and a high risk of complications to 
support code 99223 for May 1, 2022. 
 
The records do not document medical decision making of moderate complexity that would require multiple 
diagnoses, moderate amount and complexity of data reviewed and moderate risk of complications. The records 
do not support the billing of code 99232 for May 2, 2022, and May 3, 2022. 
 
We looked at this coder's review, the file, and Medicare rules. 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 procedure codes 99223 and 99232 billed for May 1, 2022, to May 3, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a urine PCR (polymerase chain reaction) panel provided on October 11, 
2021. 
 
You asked the Plan to pay for the testing panel. You say that this test was medically necessary. The Plan denied 
your request. The Plan says that a urine PCR panel is not the standard of care and is not considered medically 
necessary in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. The rules also 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. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing panel. Our physician reviewer 
found that the case file notes that records were requested and received from the laboratory, but no such records 
were included and submitted to us for review. An office note from the enrollees primary care physician has 
been identified, but it is from over a year after the date in question and is not relevant to the item in dispute. 
Interestingly, the note corresponds to the data form claim that the item in dispute is a general health panel; 
however, everything else indicates that the item in dispute is procedure code 87640 for a molecular/PCR urine 
panel. In summary, the health plan has failed to provide documentation that supports its denial regarding the 
date of service and item in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing panel have been met. Therefore, we decided that the Plan has to pay 
for a urine PCR (polymerase chain reaction) panel provided on October 11, 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: Favorable

 
We decided that the Plan has to pay for the lab services provided on May 5, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that experimental 
services are not covered. 
 
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 lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. It should also be noted that the Plan made a decision based on medical necessity, but did 
not submit medical records from the contracted provider. Therefore, we decided that the Plan has to pay for the 
lab services provided on May 5, 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: Favorable

 
We decided that the Plan has to pay for the lab services provided on March 10, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that experimental 
services are not covered. 
 
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 lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan.  It should also be noted that the Plan made a decision of medical necessity, but did not 
submit medical records from the contract provider. Therefore, we decided that the Plan has to pay for the lab 
services provided on March 10, 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: 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 enrollee's ability to regain maximum function 
will be in jeopardy if the inpatient rehabilitation is denied. The Plan denied your request. The Plan says the IRF 
care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as 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 enrollee was admitted to an acute hospital with pain in the abdomen and was 
found to have perforated sigmoid diverticulitis. The enrollee is medically stable and does not need a physician's 
supervision three times a week 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 May 11, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says that the enrollee has not tried and failed the preferred drug, zoledronic 
acid. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have been met. Our physician reviewer found the provided documentation indicates that the 
enrollee has not tried and failed the preferred drug, zoledronic acid. The reviewer also found that the 
documentation supports that the plan's required drug, zoledronic acid, an alternative bisphosphonate, would not 
be appropriate for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria have 
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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia (J0897).  
 
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 Latuda. 
 
You asked the Plan to pre-approve Latuda. You say that the enrollee has been stable on this medication for 
almost a year. The Plan denied your request. The Plan says the requested drug is considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the requested drug is not covered under 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 Latuda.
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 enrollee needs the rehabilitation in order to 
regain maximum function. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility, home 
with home health services, or home with outpatient therapy. 
 
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 enrollee was admitted to an acute hospital with left knee infected wound from 
trauma and treated conservatively. The enrollee is medically stable with no other acute medical problems or 
events and does not need a physician's supervision three times a week 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.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that this service was medically necessary. The Plan denied 
your request. The Plan says that coverage criteria has not been 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 Zilretta. Our reviewer says that Zilretta 
is medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis 
of osteoarthritis of the knee. The record indicates that the enrollee has had benefit from the requested drug 
previously.  The requested drug is being used for its current Food and Drug labelled indication. The Food and 
Drug Administration has not restricted its use to a single 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure improves quality of life. 
The Plan denied your request. The Plan says the request is 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 the requested services. Our physician 
reviewer found that the requested Intracept procedure is experimental. More research is needed to show its 
efficacy. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care (99225) provided on August 30, 2022. 
 
You asked the Plan to pay for the observation care. The Plan denied your request. The Plan says the place of 
service was 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. 
 
In this case, the CPT Code Manual definition of code 99225 is "Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit". 
 
We find that CPT code 99225 is not supported in the medical record. Specifically, the outpatient observation 
code was billed with an outpatient place of service. The records show that the enrollee was under inpatient 
status on the date of service in question. It is inappropriate to bill observation care and an outpatient POS code 
when the enrollee is under inpatient status. Based on this information, we decided that Medicare rules for 
coverage of the observation care have not been met. Therefore, we decided that the Plan does not have to pay 
for the observation care (99225) provided on August 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit for the evaluation and 
management of a new patient (99204), radiologic examination, spine, cervical (72040), Imaging for evaluation 
of swallowing function (74230), and X-ray of part of lower jaw (70100) provided on November 18, 2022. 
 
You asked the Plan to pay for an office visit and X-rays. You say that the services were medically necessary. 
The Plan denied your request. The Plan says place of service 11 (office) was billed, however, the 
documentation received does not support the code billed as the visit was not performed in an office or other 
outpatient setting but rather in a mobile setting at a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code assigned by the 
physician/practitioner for the professional component (PC) of a service shall be the setting in which the 
enrollee received the technical component (TC) service.   
 
If the mobile unit is serving an entity for which another POS code already exists, providers should use the POS 
code for that entity. This claim was billed with an office POS code, but the records show that the member was a 
skilled nursing facility (SNF). As such, the SNF POS code should be reported.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
office or other outpatient visit for the evaluation and management of a new patient (99204), radiologic 
examination, spine, cervical (72040), Imaging for evaluation of swallowing function (74230), and X-ray of part 
of lower jaw (70100) provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Hyaluronan or derivative, durolane, for intra-articular 
injection, 1 mg (code J7318) provided on May 12, 2022. 
 
You asked the Plan to pay for the Hyaluronan or derivative, durolane, for intra-articular injection. You say that 
you are supposed to pay 20% of the cost of the drug administered during the procedure and all other costs for 
the procedure are fully covered by your Plan. You say that you are covered at 100% for this service after your 
$35 copay. The Plan denied your request. The Plan says there is no authorization for this drug, and it is not a 
covered benefit. The medical records do not show a referral from an in-network provider. 
 
The Plan must contract says some of the services listed in the Medical Benefits Chart are covered only if 
your doctor or other network provider gets approval in advance (sometimes called "prior authorization") from 
us. Covered services that need approval in advance are marked in the Medical Benefits Chart in bold. You can 
find this information on page 64 of the Plans 2022 Evidence of Coverage. 
 
We looked at the file the Medicare rules and the Plan rules. The file shows that there is no authorization for this 
injection. Therefore, we decided that the Plan does not have to pay for a Hyaluronan or derivative, durolane, 
for intra-articular injection, 1 mg (code J7318) provided on May 12, 2022.