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

 
We decided that the Plan does not have to pay for code 99285 provided on October 21, 2022. 
 
You asked the Plan to pay for code 99285. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the service billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
 
 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 code 99285. Our reviewer says that the documentation does 
not support the code billed. Our reviewer found the documentation does not support the level of service billed. 
The emergency department visit does not include documentation of history and exam to support evaluation and 
management service. A history and examination report was not included in the documentation. Therefore, the 
documentation does not support code 99285 as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 provided on October 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for Part B drugs, an X-Ray examination, and 
ultrasound provided on October 25, 2022. 
 
You asked the Plan to waive the cost-sharing for Part B drugs, X-Ray, and ultrasound. You say that you were 
given misinformation about this cost-sharing. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs, $5 copayment for X-Ray, and $80 copayment for ultrasound. The allowed 
amounts of the Part B drugs total $11.72, resulting in a coinsurance amount of $2.35. You have been asked to 
pay $5 copayment for the X-Ray. You have also been asked to pay the allowed amount of $60.69 for the ultrasound, because this amount is less than the $80 copayment for an ultrasound. Therefore, your total cost-
sharing responsibility is $68.04. 
 
You have been asked to pay 20% coinsurance for Part B drugs, $5 copayment for X-Ray, and less than $80 
copayment for ultrasound. These items/services fall within the "Medicare Part B prescription drugs" and 
"outpatient diagnostic tests and therapeutic services and supplies" benefit categories. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost-sharing for Part B drugs, an X-Ray examination, and ultrasound provided on October 25, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from June 22, 2021, to 
June 27, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration of the DRG adjustment. The Plan denied your request. 
The Plan says it is recommended that code J96.01 be removed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 640. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the documentation does not support diagnosis code J96.01 as the patient did not require high flow oxygen, 
bilateral positive airway pressure (BiPAP), or vent support and was stable on low dose oxygen for mild 
hypoxia. Therefore, the documentation more supports DRG 641 without acute 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 rendered from June 22, 2021, to June 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a TTE. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found clinical guidelines do not support carrying out a TTE in this setting. In summary, there is no 
supportive evidence for the medical necessity of a TTE 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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve the pacemaker. You say that this is medically necessary. The Plan denied 
your request. The Plan says this denial is appropriate given the relevant clinical guidance. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are not covered outside of a 
Medicare-approved study. 
 
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 pacemaker. Our reviewer says that  
Our physician reviewer found  
 
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 pacemaker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a leadless pacemaker.
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 can benefit from an IRF as they cannot 
be adequately cared for at a lower level of care. The Plan denied your request. The Plan says an IRF admission 
is not medically necessary, and the enrollee's needs can be provided safely in other settings. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 12, 2021, 
through March 19, 2021, and billed with diagnosis code J96.01. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis J96.01 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of J96.01. 
 
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 secondary diagnosis code J96.01-acute respiratory 
failure with hypoxia. 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 documentation does not support the secondary 
diagnosis of J96.01-acute respiratory failure with hypoxia. Our physician reviewer found the member's oxygen 
saturation level was at 93 percent on day of admission, thereafter improving, ranging from 94 - 98 percent. The 
member's respiration rate was 16-20 throughout admission following treatment in the emergency department. 
The notes continued to state, "Continue oxygen via nasal cannula, wean as possible". The member was treated 
with duonebs, incentive spirometry, oxygen by nasal cannula, and pulse oximetry was monitored. There was no 
evidence of partial pressure of oxygen less than 60 percent or oxygen saturation less than 91 percent. There was 
also no documentation of treatment consistent with acute respiratory failure with hypoxia, which would include 
administration of oxygen 5 litters or more, or provision of bilevel positive airway pressure and/or mechanical 
ventilation. Therefore, secondary diagnosis of J96.01-acute respiratory failure with hypoxia is not the 
appropriate secondary diagnosis.  
 
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 March 12, 2021, through March 19, 2021, and billed with diagnosis 
code J96.01.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this injection does 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 the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there is no concordant physical examination and radiological imaging demonstrating a 
diagnosis of lumbar radiculopathy. The review has determined that the enrollee does not meet the coverage 
criteria for this injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar epidural steroid injection.
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 you are requesting reconsideration for the denial of 
an IRF admission as the enrollee meets the full criteria. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to an IRF. 
 
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 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve interstitial radiation therapy. 
 
You asked the Plan to pre-approve interstitial radiation therapy. You say that the enrollee needs this procedure 
done quickly. The Plan denied your request. The Plan says that this is not medically necessary. 
 
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.  
 
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 interstitial radiation therapy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found bridge therapy is used to decrease tumor progression and the dropout rate from 
the liver transplantation waiting list. It is also an effective way to help select the best patients for transplant and 
is recommended for patients who meet the transplant criteria. Use is recommended by guidelines recognizing 
increased risk in patients with a bilirubin above 2. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of interstitial radiation therapy have been met. Therefore, we decided that the Plan 
has to pre-approve interstitial radiation therapy.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 26075 and 26746 provided on October 25, 
2022. 
 You asked the Plan to pay for procedure codes 26075 and 26746. You say that the medical records support the 
use of modifier 59 with procedure codes 26075 and 26746. The Plan denied your request. The Plan says the 
medical records do not support the use of modifier 59 with procedure codes 26075 and 26746. 
 
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 26075 and 26746 are column II codes to column I codes 26540 and 
26075 respectively; however, 26075 and 26746 were billed with a modifier.  
 
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 procedure codes 26075 and 26746. Our reviewer says that 
the medical records do not support the use of modifier 59 with procedure codes 26075 and 26746. Our reviewer 
found the operative report describes open treatment of articular fracture, involving metacarophalangeal or 
interphalangeal joint, however this procedure would be included in repair of a collateral ligament or a 
metcarpophalangeal or interphalgeal joint. The procedure report does not support a different session, different 
procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate 
injury (or the area of injury in extensive injuries) not ordinarily encountered or performed on the same day by 
the same individual. The records do not support the use of modifier 59 with procedure code 26746. 
 
The operative report describes loose body removal; however, this procedure would be included in repair of a 
collateral ligament or a metcarpophalangeal or interphalgeal joint. The procedure report does not support a 
different session, different procedure or surgery, different site or organ system, separate incision/excision, 
separate lesion, or separate injury (or the area of injury in extensive injuries) not ordinarily encountered or 
performed on the same day by the same individual. The medical records do not support the use of modifier 59 
with procedure code 26075. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 26075 and 26746 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 26075 and 26746 provided on October 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chimeric antigen receptor T-cell (CAR-T) therapy; 
CAR-T cell administration, autologous (0540T). 
 
You asked the Plan to pre-approve CAR-T therapy. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. This 
treatment is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 
 
 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 CAR-T therapy. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of chronic myelogenous leukemia. The Food and Drug Administration has not stated that the 
requested drug, as prescribed, is indicated for the enrollee's condition. The Medicare approved drug compendia 
does not contain a supportive citation for the use of the requested drug, as prescribed, in the enrollee's clinical 
situation. 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 CAR-T therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous 
(0540T).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97010 and 97014 billed for date of service 
September 27, 2022. 
 You asked the Plan to pay for procedure codes 97010 and 97014. The Plan denied your request. The Plan says 
procedure codes 97010 and 97014 are not 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. We also find that procedure code 97014 has a Status Indicator 
of I on the Physician Fee Schedule. This means that procedure code 97014 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 97010 and 97014 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 97010 and 
97014 billed for date of service September 27, 2022.