Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (J9356) provided on February 18, 2022. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code J9356 is not supported in the medical record. Specifically, this code is a type G 
procedure that was billed with a type T or S procedure without a required modifier 25. Based on this 
information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we 
decided that the Plan does not have to pay for injections (J9356) provided on February 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 8, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee 
without contrast (73721). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have knee pain. The record indicates that you have osteoarthritis of the knee. The record does 
not indicate that you have tried and failed conservative nonpharmacologic therapy. The record provided does 
not indicate how the requested test would change your management at this time. The requested service is not 
medically necessary and reasonable for the diagnosis and treatment for your clinical condition at this time. 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the right knee without contrast (73721).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97530, 97140, 97110, 97162, & 97112) 
provided on June 30, 2022 to August 15, 2022. 
 
You asked the Plan to pay for the therapy services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says Original Medicare is liable for payment for this service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for therapy services (97530, 97140, 97110, 97162, & 97112) 
provided on June 30, 2022 to August 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Victoza. 
 
You asked the Plan to pre-approve Victoza. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Victoza is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Victoza.  
 
Benefits for Victoza may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Ziextenzo (Q5120). 
 
You asked the Plan to pre-approve Ziextenzo. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that step-therapy rules for coverage of the requested drug 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided an EOC for the 2023 benefit year. 
Without the EOC, we are unable to determine whether the Plan has applied step therapy to certain Part B drugs 
in 2023 or whether the Plan has disclosed the step therapy requirements as required by Medicare rules. It is the 
Plan's responsibility to substantiate its denial with evidence. In this case, the Plan's denial has not been 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pre-approve treatment 
with Ziextenzo (Q5120).  
 
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: Favorable

 
We decided that the Plan has to waive the coinsurance and copayment for ambulance transportation, an 
emergency room (ER) visit, and inpatient mental health care provided from August 27, 2022, to September 8, 
2022. 
 
You asked the Plan to waive the coinsurance and copayment for the ambulance transportation, ER visit, and 
inpatient mental health care. You say that you did not request the services, and you did not receive proper 
treatment. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for ambulance services, emergency care, 
and inpatient mental health care. 
 
The Plan says you must pay a 20% coinsurance for the ambulance transportation, a $120 copayment for the 
emergency care, and a $2,339 copayment for the inpatient mental health care. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for the ambulance transportation, ER visit, and 
inpatient mental health care. Therefore, we decided that the Plan has to waive the coinsurance and copayment 
for ambulance transportation, an emergency room (ER) visit, and inpatient mental health care provided from 
August 27, 2022, to September 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99153 & G0269 provided on October 7, 
2021. 
 You asked the Plan to pay for procedure codes 99153 & G0269. You say that this service was medically 
necessary. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting. Code 
G0269 is not separately payable. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Code G0269 has a status indicator of "B" 
and payment is always bundled with another service. Therefore, we decided that the Plan does not have to pay 
for procedure codes 99153 & G0269 provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for observation care provided on January 8, 2022. 
 
You asked the Plan to pay for observation care. You say that the in-network hospital was unable to admit you 
The Plan denied your request. The Plan says that the provider is out-of-network and authorization was not 
obtained prior to services being rendered. 
 
The Plan must follow Medicare rules. Medicare says that plans must pay for emergency and urgently needed 
services. The prudent layperson would have believed that someone suffering from a heart attack would have an 
emergent need for services. This was a clear emergency situation. The plan must provide care outside of the 
network when network care is unavailable. You had no choice where to receive services when the ambulance 
was called. You were told by the ambulance that you could not go to the plans in-network hospital due to 
staffing and overcrowding issues. Based on this information, we decided that Medicare rules for coverage of 
the hospital services have been met. Therefore, we decided that the Plan has to pay for observation care 
provided on January 8, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery for coronary 
angiography, including intraprocedural injections for coronary angiography, imaging supervision and 
interpretation, with left heart catheterization including intraprocedural injections for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the left heart 
catheterization is not medically necessary at this time. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is the medical appropriateness and necessity for performance of cardiac 
catheterization. A radionuclide stress test was normal. Guidelines do not support a need for cardiac 
catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically appropriate and necessary in this enrollee's 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve catheter placement in coronary artery for coronary angiography, including 
intraprocedural injections for coronary angiography, imaging supervision and interpretation, with left heart 
catheterization including intraprocedural injections for left ventriculography, when performed (93458).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for observation care provided on January 9, 2022. 
 
You asked the Plan to pay for the observation care. You say that the in-network hospital was not able to admit 
you. The Plan denied your request. The Plan says that the provider is out-of-network and authorization was not 
obtained prior to services being rendered. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for observation 
care provided on January 9, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network exception for psychotherapy services 
to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve an out-of-network exception for psychotherapy services to be provided by 
an out-of-network provider. The Plan denied your request. The Plan says the requested service is not eligible 
for coverage because there are in-network options available within 30 miles of the enrollee's home. The 
enrollee may want to consider using her out-of-network benefits or accessing an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan will cover services from either network or out-of-network providers, as long as the 
services are covered benefits and are medically necessary. However, if you use an out-of-network provider, 
your share of the costs for your covered services may be higher. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an out-of-
network exception for psychotherapy services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chemodenervation of muscle(s); neck 
muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) (64616) 
and injection, onabotulinumtoxina, 1 unit (J0585) provided August 5, 2022. 
 
You asked the Plan to waive the copayment for the outpatient procedure. You say that you had the same exact 
procedure done on May 6, 2022, with the same service code, same amount, same place and doctor and there 
was no copay. 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 Medicare Part B drugs and $300 copayment for surgery services in an outpatient hospital.  
 You have been asked to pay $481.52 ($181.52 + $300) for the outpatient procedure. This item/service falls 
within the Medicare Part B prescription drugs Outpatient hospital services benefit category. 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 copayment for chemodenervation of muscle(s); neck muscle(s), excluding muscles 
of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) (64616) and injection, 
onabotulinumtoxina, 1 unit (J0585) provided August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12011 provided on March 19, 2022. 
 
You asked the Plan to pay for procedure code 12011. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 12011 is not supported in the medical record. Specifically, this service was included in 
the 90 day global surgery package of code 26720 billed on January 17, 2022. Based on this information, we 
decided that Medicare rules for coverage of procedure code 12011 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 12011 provided on March 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 22, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve continuous glucose monitor (CGM). You say that the enrollee has a difficult 
time pricking fingers due to the enrollee's age and conditions. The Plan denied your request. The Plan says the 
enrollee does not require insulin three or more times daily. 
 
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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of continuous glucose monitor (CGM) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose 
monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 14, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 29, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 29, 2022.