Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre reader and sensors. 
 
You asked the Plan to pre-approve a Freestyle Libre reader and sensors. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre reader and sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre reader and sensors.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group 
(DRG) 871 provided from October 19, 2021, to October 21, 2021. 
 
You asked the Plan to pay for the inpatient hospital services with DRG 871. You say that the medical records 
support the billing of the principal diagnosis code B37.7 with DRG 871. The Plan denied your request. The 
Plan says the medical records do not support the billing of the principal diagnosis code B37.7 with DRG 871. 
 
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 principal diagnosis code, B37.7, defined as candidal 
sepsis. 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 with DRG 
871. Our reviewer says that the medical records do not support the billing of the principal diagnosis code B37.7 
with DRG 871. Our physician reviewer found candidal sepsis was not supported in the provided 
documentation. Sepsis 3 criteria was not sufficiently met. The enrollee's vitals were relatively stable, labs were 
not indicative of end-organ damage as there was normal bilirubin. Cr improved from prior hospital stay, normal 
platelets, and they were not ill-appearing. Candida was found in the blood but there was no direct connection 
that it was causing a systemic response with organ damage as is defined by candidal sepsis.  
 
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 the inpatient hospital services with diagnosis related group (DRG) 871 provided from October 19, 2021, to 
October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service January 17, 
2022. 
 
You asked the Plan to pay for code 99291. You say that the medical records support this billing. The Plan 
denied your request. The Plan says the records do not support the billing of this code. 
 
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 99291 is a critical care visit of 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-
specific code, meaning that the total time spent providing critical care services must be documented in the 
medical record.  The medical record does not include the number of minutes the provider spent providing this 
service. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for date of 
service January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on April 19, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 the lumbar-sacral orthosis (LSO) rendered on April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on December 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the place of service code is correct. The Plan 
denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
 We find that the lab testing services were not billed with a modifier suitable for payment. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the pathology services provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection (62321). 
 
You asked the Plan to pre-approve the injection. You say that the injection is medically necessary. The Plan 
denied your request. The Plan says that the documentation provided does not support that the criteria have been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the 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 the injection. Our reviewer says that the 
requested injection is medically necessary. Our physician reviewer found the provided documentation indicates 
the enrollee has chronic cervical radiculopathy. The enrollee has tried physical therapy and clinical trials. The 
reviewer found that the documentation supports a diagnosis of spinal stenosis. Therefore, the reviewer found 
that the 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 the injection have been met. Therefore, we decided that the Plan has to pre-
approve an epidural steroid injection (62321).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service February 26, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment for 
code 74177. 
 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 74176 
is a column II code to column I code 74177. 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 74176 billed for date of service February 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular pathology testing of the L3A1 SMAD3 
TGFB2 TGFBR1 TGFBR2 SMAD2 TGFB3 genes. 
 
You asked the Plan to pre-approve gene testing. You say that you believe that this testing should be approved 
because you have digestive issues that this testing could explain. The Plan denied your request. The Plan says 
this is not covered for your condition. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 A test is considered screening when it is provided in the absence of signs/symptoms of illness or injury. In this 
case, the genetic test at issue is used to determine the presence of inherited cancer-causing mutations. However, 
the records do not show that the enrollee has any signs or symptoms suggestive of cancer. The documentation 
supports that this testing is requested due to a family history alone of breast cancer and melanoma. This would 
be considered screening testing which is excluded from Medicare coverage. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve molecular 
pathology testing of the L3A1 SMAD3 TGFB2 TGFBR1 TGFBR2 SMAD2 TGFB3 genes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the laboratory services rendered on 
December 19, 2021. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the coinsurance was applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 15% coinsurance for Medicare-covered lab services.  
 
Review of the file shows that the enrollee received lab services on December 19, 2021. The enrollee has been asked to pay a 15% coinsurance for these services. These services fall within the Medicare-covered lab services 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the laboratory services rendered 
on December 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 28, 2022, and billed 
with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81335, 81355, and 
81479. 
 
You asked the Plan to pay for genetic testing. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 
28, 2022, and billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 
81335, 81355, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the knee to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an MRI of the knee to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a magnetic resonance imaging (MRI) of the knee to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular embolization. 
 
You asked the Plan to pre-approve vascular embolization. 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 vascular embolization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found prostatic arterial embolization (PAE) is not medically reasonable and necessary in 
this case. PAE is considered an experimental technique to treat symptomatic benign prostatic hyperplasia 
(BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most recent 
American Urological Association guidelines do not recommend this procedure outside of a clinical trial setting 
due to the heterogeneity in the available literature and safety concerns regarding radiation exposure, 
postembolization syndrome, vascular access, technical feasibility, higher clinical failure rate compared with 
more traditional methods. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vascular embolization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve vascular embolization.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75716 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 75716. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 75716 is bundled into payment for code 37225.  
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 75716 
is a column II code to column I code 37225. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 75716 billed for date of service March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening provided on 
September 15, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. Cardiovascular risk assessment panels are only covered for certain 
indications. 
 
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that 
the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the 
cardiac risk assessment genetic screening provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for carpal-tunnel therapeutic injection services (20526) billed for 
date of service October 25, 2021. 
 
You asked the Plan to pay for carpal-tunnel therapeutic injection services. You say that you have provided 
documentation to support the services billed. The Plan denied your request. The Plan says rules for payment 
have not been met because the available records do not support the services billed. 
 
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 20526 is "Injection, therapeutic (eg, local anesthetic, 
corticosteroid), carpal tunnel." 
 
 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 carpal-tunnel therapeutic injection services. Our reviewer 
says that the CPT code at issue does not meet criteria for payment. Our reviewer found that the procedure 
report does not include documentation that a therapeutic injection for carpal tunnel was provided. The 
documentation describes an injection was given for tarsal tunnel syndrome, bilateral. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of carpal-tunnel therapeutic injection services have not been met. Therefore, we 
decided that the Plan does not have to pay for carpal-tunnel therapeutic injection services (20526) billed for 
date of service October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 16, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81355, 81335, 81406, 81407, 0031U, 0032U, 
and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 16, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81355, 81335, 
81406, 81407, 0031U, 0032U, and 0033U.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from June 24, 2021, to July 15, 
2021. 
 
You asked the Plan to pay for the home health services. You say that you were not aware that the Plan's policy 
requires the Request for Anticipated Payment (RAP) to be submitted by a certain time. The Plan denied your 
request. The Plan says that the RAP was not submitted until July 15, 2021. As this was more than 30 days late, 
no payment is made on the final claim. 
 
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. The Plan has not supported its denial rationale with documentation. There is no 
evidence to confirm when the RAP was submitted. As such, the denial of payment of the final claim is not 
supported. Therefore, we decided that the Plan has to pay for the home health services provided from June 24, 
2021, to July 15, 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.