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

 
We decided that the Plan has to pay for procedure codes 81321 and 81351 provided on May 23, 2022. 
 
You asked the Plan to pay for procedure codes 81321 and 81351. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for procedure codes 81321 and 81351 by a contract provider. The file does not show 
that the plan provided notice that procedure codes 81321 and 81351 would not be covered. Under Medicare 
rules, this means procedure codes 81321 and 81351 are considered approved by the plan. Therefore, we 
decided that the Plan has to pay for procedure codes 81321 and 81351 provided on May 23, 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 Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 97010 is considered bundled 
and 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 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. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 6, 2022. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the services 
were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. Wherever such a combination exists, there is a use additional code note at the 
etiology code, and a code first note at the manifestation code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the record shows that the claim was billed 
with diagnosis code J70.5. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. Therefore, we decided that the Plan does not have to pay for the ambulance 
services provided on July 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rhythm electrocardiogram (ECG) (procedure code 93040) 
provided to the enrollee on September 6, 2022. 
 
You asked the Plan to pay for the ECG. You say that this was medically necessary. The Plan denied your 
request. The Plan says a review of the documentation does not support that this code was performed as 
indicated. 
 
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 93040 is "Rhythm ECG, 1-3 leads; with interpretation 
and report." 
 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 ECG. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the billing and medical records 
provided indicate that Current Procedural Terminology (CPT) code 93000 was billed on the same date of 
service as CPT 93040 59 by the same provider and was paid by the health plan. There is a bundled relationship 
between CPT 93000 and CPT 93040. Per National Comprehensive Cancer Network (NCCI) guidelines, a 
modifier is allowed to unbundle the two codes, providing the medical documentation supports the use of a 
modifier. In this case the medical records provided does not validate that 93040-59 was performed as a distinct, 
separate procedure, not related to CPT 93000; therefore, this service cannot be verified, and the use of a 59 
modifier is not appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ECG have not been met. Therefore, we decided that the Plan does not have 
to pay for a rhythm electrocardiogram (ECG) (procedure code 93040) provided to the enrollee on September 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for an office visit, diabetic 
shoes, and inserts. 
 
You asked the Plan to pre-approve the referral. You say that more visits need to be authorized. The Plan denied 
your request. The Plan says this request does not meet the exception rules for an out-of-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 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 
an out-of-network referral for an office visit, diabetic shoes, and inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) and silicone heel stabilizer 
rendered on October 6, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ankle-foot orthosis is covered when specific 
criteria 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of pain in the 
left ankle and joints of the left foot. The progress note dated February 14, 2022 and March 7, 2022 do not 
contain any documentation of examination of the ankle. The clinical documentation does not support that the 
enrollee in this case requires stabilization for medical reasons and has the potential to benefit functionally. The 
services were not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the ankle-foot orthosis (AFO) and silicone heel stabilizer rendered on October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you would be hospitalized due to an inability to 
breathe without this equipment. The Plan denied your request. The Plan says the records do not show failure of 
treatment with a bilevel positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous 
and/or bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical 
condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).

You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that you meet criteria for coverage of this procedure. The Plan denied your request. The Plan says this service cannot be approved because the international prostate symptom score (IPSS) was not provided, and a current prostate specific antigen (PSA) was not provided.

The Plan follows Medicare rules. Medicare rules say that this procedure may be covered when the IPPS score is greater than or equal to 12, PSA is less than or equal to 10 ng/mL, BMI is not greater than or equal to 42 and you do not have bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum.

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 transurethral waterjet ablation of prostate. Our reviewer says that this service does not meet criteria for coverage. Our physician reviewer found that the records do not show an IPSS score or PSA which are required for coverage. The records also show that your body mass index (BMI) is greater than 42 and that you have neurogenic bladder which exclude coverage of transurethral waterjet ablation of prostate.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
reader device. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM device. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the requested device. The enrollee must be insulin-treated with multiple (three or more) daily 
injections of insulin or using a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. 
 
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 use insulin 
with at least three daily injections or use an insulin pump. Based on this information, we decided that Medicare 
rules for coverage of a Freestyle Libre 2 CGM device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) reader device.
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 requires inpatient acute rehabilitation to 
increase their independence to be able to return home with an improved quality of life. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, and the enrollee can receive the care they 
need in another setting. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio therapy system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical literature does not consider this service to be standard medical treatment. 
 
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 system. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case do not document trial and failure of (or contraindication to) first-
line treatment including all pharmacologic therapy for the patient's tremor (such as propranolol, gabapentin and 
topiramate). The records also indicate the patient is currently taking phentermine which is a stimulant known to 
cause tremors; discontinuation of causative agents would be indicated prior to use of the Cala Trio system. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Cala Trio therapy system.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that the requested drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee has not tried and failed 
aorvastatin and ezetimibe, or Praluent and Repatha. 
 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 Leqvio. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred drugs. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred drugs. Therefore, the reviewer 
found that the step therapy criteria had not 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 Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
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. The Plan denied your request. The Plan says the request for an IRF admission is denied as 
not medically necessary. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you really need the requested CGM to 
check your blood sugar levels. 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM and supplies.
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. The Plan denied your request. The Plan says the IRF services you are requesting do not meet 
the requirements for approval. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission due to the amount of falls the enrollee has had. You say the assisted living facility has told the 
enrollee to leave and go to a SNF to get physical and occupational therapy at a level higher than what home 
health provides. The Plan denied your request. The Plan says the request for admission to a SNF is denied as 
not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.