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

 
We decided that the Plan does not have to pay for an additional emergency room (ER) visit provided to the 
enrollee on August 11, 2021. 
 
You asked the Plan to pay for the additional visit. You say that this should be paid for. The Plan denied your 
request. The Plan says both of the emergency department visits were provided for the same medical problems 
by the physicians of the same specialty of emergency medicine. 
 
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 - cannot be billed twice on the 
same day by physicians in the same practice and specialty. The only exception is when the evaluation and 
management services are for unrelated problems during each of the visits." 
 
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 the additional visit. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found the reviewed documentation 
indicates that the patient was seen in the emergency department (5:54:00 a.m.) by a billing provider for 
abdominal pain after swallowing heroin and was recommended by the poison center for charcoal and expectant 
management; however per the records, patient eloped prior to placement in an inpatient bed. The patient again 
arrived at the ER (3:35:00 pm), and was seen by another provider with the same complaint heroin ingestion and 
was admitted to the inpatient hospital. Both of the emergency department visits were provided for the same 
medical problems by the physicians of the same specialty emergency medicine. The review has determined that 
the records did not support that each of the ER visits were for different and unrelated problems. 
 
We looked at this coder's review, the file, and Medicare rules. As the main ER code is not supported a second 
time, the related codes are also not supported here. Based on this information, we decided that Medicare rules 
for coverage of the additional visit have not been met. Therefore, we decided that the Plan does not have to pay 
for an additional emergency room (ER) visit provided to the enrollee on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on January 12, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64454 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 injection services 
provided to the enrollee on January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on December 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not 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. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 the computed tomography (CT) scan of the head/brain rendered 
on December 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel provided to the enrollee on August 
10, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Tempus Gene Panel provided to the enrollee on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the power wheelchair. We decided that the Plan does not have to 
pre-approve the group 2 power wheelchair with single power option.  
 
You asked the Plan to pre-approve the power wheelchair. You say that the enrollee does not have legs and his 
doctor is prescribing a power wheelchair for him. The prior authorization was denied that there were not 
enough medical reasons. The Plan says that the requested group 2 power wheelchair with power tilt is not 
medically necessary. The enrollee's needs can be met with a group 2 power wheelchair with no power option 
and a request can be reviewed if submitted. 
 
We decided that the Plan has to pre-approve the group 2 power wheelchair with no power options.  
 
We also decided that the Plan does not have to pre-approve the group 2 power wheelchair with single 
power option. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
 
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 power wheelchair. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the clinical documentation supports the need of a group 2 power wheelchair (K0835) 
as being medically reasonable and appropriate as it is documented that the enrollee is willing to use power 
wheelchair, able to use in home, and has comorbidities preventing the ability to use group 1 or manual 
wheelchair. The single power option of E1002 power tilt is not medically necessary as the provider team 
documents Roho cushion is providing necessary pressure relief and there are no other documented reasons for 
power tilt being necessary.  
 
We looked at this physician's review, the file, and Medicare rules. The flip forward back cane (K0108) is a 
noncovered accessory and is not medically necessary. Based on this information, we decided that Medicare 
rules for coverage of the power wheelchair have partially been met. Therefore, we decided that the Plan has to 
pre-approve the group 2 power wheelchair with no power options and does not have to pre-approve the group 2 
power wheelchair with single power option. 
 
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that while the member will likely benefit from ongoing therapy to enhance 
rehabilitation potential, there is no evidence that this cannot safely be done at a lower level of care. 
 
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. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute rehab nursing needs identified or documented in the record. At the 
current functional level with refusal to participate in therapy, the enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. It is unlikely that the enrollee will make a significant functional progress in the predicted 7 to 10 days in 
an IRF. The enrollee's rehab needs can be met safely and provided at a lower intensity and alternate setting. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you want to be referred to the out-of-network 
provider under your new insurance. You say you need to continue care with this doctor due to prescriptions you 
must take. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 office visit in this appeal. We found no exception that would require the Plan to 
pre-approve the office visit. Therefore, we decided that the Plan does not have to pre-approve the office visit to 
be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for general intravenous therapy (IV), 
chemotherapy IV administration, and Medicare Part B prescription drugs provided from January 12, 2022, to 
January 18, 2022. We also decided that the Plan does not have to waive the copayment for outpatient hospital 
services provided from January 12, 2022, to January 18, 2022.  
You asked the Plan to waive the coinsurance for general intravenous therapy (IV), chemotherapy IV 
administration, and Medicare Part B prescription drugs. You also asked the Plan to waive the copayment for 
outpatient hospital services. You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says you were charged the correct cost sharing amount. 
 
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 a 20% 
coinsurance for chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B. for 
Medicare Part B prescription drugs.  Your contract with the Plan also clearly says that you must pay a $175 
copayment for outpatient hospital visits other than emergency room visits, for Medicare-covered dialysis, for 
Medicare-covered lab services, for Medicare-covered outpatient surgery, for Medicare-covered partial 
hospitalization services, for Medicare Part B drugs, and for Medicare-covered observations services in an 
outpatient hospital setting.  
 
You have been asked to pay a total of $1085.66 in coinsurance, which is 20% of the allowed amount for 
general intravenous therapy (IV), chemotherapy IV administration, and Medicare Part B prescription drugs 
($5010.77 allowed amount x 20% coinsurance = $1,002.15), ($417.56 allowed amount x 20% coinsurance = 
$83.51) and ($1002.15 + $83.51 = $1085.66). General intravenous therapy (IV), chemotherapy IV 
administration, and Medicare Part B prescription drugs benefit category. You have also been asked to pay a 
$175 copayment for outpatient hospital services. 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 coinsurance for 
general intravenous therapy (IV), chemotherapy IV administration, and Medicare Part B prescription drugs 
provided from January 12, 2022, to January 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee still needs significant PT and 
modifications due to her limitations. The Plan denied your request. The Plan says 13 additional physical 
therapy sessions are reasonable or necessary at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition. Our reviewer found that the patient has had prior therapy 
approved and the documentation does not reveal that the patient requires the unique skills of a professional 
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist without the outcome and evidence of ongoing 
need from the prior approved therapy. Our physician reviewer also found that the requested services are not 
part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or 
slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 13 additional physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, gel-one (CPT code J7326). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the request does not meet medical necessity for viscosupplementation injections 
due to no imaging confirming the presence of osteoarthritis of the knee. The Plan states the enrollee does not 
meet non-preferred exception as there is no documentation that they have received the non-preferred 
medication within the past 365 days, no documentation that the enrollee has tried and experienced a documented intolerable adverse event to at least two of the preferred products Orthovisc, and Synvisc or 
Synvisc One. 
 
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 the medication. Our physician reviewer 
found there is no indication that the patient has tried and failed the required drug(s). There is no indication that 
the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronan or derivative, gel-one (CPT code J7326).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not 
tried and failed a 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 physician reviewer found 
that the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a new 
start. The Plan requires a trial of zoledronic acid before they will approve the requested drug. The provided 
records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred intravenous step one alternative.  
 
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 not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on December 8, 2021. 
 
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 code G0483 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 G0483 is definitive drug testing, 22 or more drug classes. 
 
 
 
 
 We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation 
of testing of 22 or more drug classes. 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 drug 
testing rendered on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a multiplex PCR respiratory panel (6+ pathogens) provided 
to the enrollee on September 20, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the fixed nature of these multiplex panels includes pathogens that cause infections different 
enough that simultaneous testing for these pathogens should be rare. 
 
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 87633 is not supported in the medical record. Specifically, this is for testing of six or 
more pathogens. 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 a multiplex PCR respiratory panel 
(6+ pathogens) provided to the enrollee on September 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 8mg tablets. 
 
You asked the Plan to pre-approve Ondansetron. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says the drug is not being used as a full therapeutic replacement for IV anti-
emetic drugs administered at the time of the cancer chemotherapy treatment. Coverage criteria has not been 
met. 
 
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 Ondansetron 8mg tablets.