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

 
We decided that the Plan does not have to pay for Bupivacaine HCL injection (J3490). 
 
You asked the Plan to pay for Bupivacaine HCL injection. You say that this drug was a necessary part of the 
enrollee's treatment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pay for Bupivacaine HCL injection. Our reviewer 
says that the requested Bupivacaine HCL injection is not medically necessary. Our physician reviewer found 
the reviewer found that the provided documentation does not indicate a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures outside of him working out 3 days a week. The 
provided recent imaging shows minimal degenerative changes. The reviewer found that corticosteroid 
injections with long-acting anesthetic (bupivacaine) for knee osteoarthritis over more conservative measures or 
at least a trial and failure of those more conservative measures. Therefore, the reviewer found that the requested 
Bupivacaine HCL injection is not medically reasonable or 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 Bupivacaine HCL injection have not been met. Therefore, we decided that the 
Plan does not have to pay for Bupivacaine HCL injection (J3490).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit have not been met. Specifically, the record shows that the claim 
was billed with only one diagnosis code, F01.50. 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 services provided on October 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93042, 99053, and 99285 billed for date of 
service December 18, 2021. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the claim. 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 CPT code. 
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): A comprehensive history; A comprehensive examination; 
and medical decision making of high complexity. In addition, CPT code 99285 usually includes a presenting 
medical problem of high severity and immediate significant threat to life or physiologic function. The records 
show that the enrollee was in no acute distress, no respiratory distress, and had no signs of dyspnea, 
diaphoresis, syncope, palpitations, or edema. The records do not show that the enrollees presenting problems 
posed an immediate significant threat to life. Based on this information, we decided that the Medicare rules for 
coverage have not been met.  
 
In this case, we have confirmed that code 93042 is a column II code to column I code 93010. The code at issue 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
93042, 99053, and 99285 billed for date of service December 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary.  
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the member does not need this item. Our physician reviewer found the records document that the home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4223 billed for date of service August 17, 
2022, to August 18, 2022. 
 You asked the Plan to pay for procedure code A4223. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code A4223 is 0. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4223 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4223 billed for date of service August 17, 2022, to August 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection, ferumoxytol, for treatment of iron 
deficiency anemia, 1 mg (Q0138). 
 
You asked the Plan to pre-approve an injection. You say that the requested injection is medically necessary for 
the enrollee due to the enrollees clinical history and current medical condition. The enrollees cancer is 
worsening, and she has anemia. The Plan denied your request. The Plan says Medicare rules require that in 
addition to anemia, the enrollees ferritin level must be less than 100. The enrollee does not meet criteria for 
approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say to receive approval for the requested medication, 
the enrollees ferritin level must be less than 100. The records show that the enrollees ferritin level was 541 on 
February 23, 2023; therefore, even though the enrollee is anemic, she does not meet criteria for approval for the 
requested medication. Based on this information, we decided that Medicare rules for coverage of an injection 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an injection, ferumoxytol, 
for treatment of iron deficiency anemia, 1 mg (Q0138).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service November 
18, 2022. 
 You asked the Plan to pay for procedure code 99214. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99214 is bundled into payment for code 20610. 
 
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 99214 
is a column II code to column I code 20610. 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 99214 billed for date of service November 18, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0745 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code was not 
billed with the required modifier. 
 
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 CPT code E0745 was not billed with a modifier to indicate whether the equipment at issue was 
rented or purchased. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code E0745 
billed for date of service July 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on October 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim is coded correctly. The Plan denied 
your request. The Plan says the diagnosis code is not acceptable as a primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim was billed with a primary diagnosis code of T45.7X5A, adverse effect of anticoagulant antagonists, 
vitamin K and other coagulants, initial encounter. When coding an adverse effect of a drug that has been 
correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect 
followed by the appropriate code for the adverse effect of the drug. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the emergency room services provided on October 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on August 18, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary.  
 Our physician reviewer found the transportation via ambulance from the hospital to a rehabilitation facility was 
not medically necessary. The enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided 
by other means (stretcher van, wheelchair van) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on August 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra ACTpen. 
 
You asked the Plan to pre-approve Actemra ACTpen. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Actemra ACTpen.  
 
Benefits for Actemra ACTpen 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 28, 2022, to 
June 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission dates reported on the claims at issue 
do not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claims at issue have not been met. Therefore, 
we decided that the Plan does not have to pay for the home health services provided from April 28, 2022, to 
June 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) 
provided on September 1, 2022. 
 
You asked the Plan to pay for a bone replacement graft for ridge preservation. You say that you were in such 
pain this was necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft for ridge preservation (D7953) provided on September 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that this enrollee is receiving chemotherapy and 
needs this medication to help control the nausea and vomiting that can happen from receiving these treatments. 
The Plan denied your request. The Plan says the appeal for Ondansetron does not meet Medicare criteria for 
coverage under Part B. The Plan also says this medication falls under Part D coverage. 
 
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.  
 
  Benefits for Ondansetron 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D testing provided on March 14, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the screening 
testing is not a Medicare benefit. 
 
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. 
 
The test at issue in this appeal was requested for screening purposes. There are no medical records from the 
treating physician to show that the testing was ordered based on a specific medical problem. Reimbursement is 
not allowed for routine screening for vitamin D deficiency in asymptomatic individuals. Medicare does not 
cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
Vitamin D testing provided on March 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 18, 2022, to 
January 22, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
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 diagnosis code G93.41, defined as metabolic 
encephalopathy. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the submitted records do not support the billing of 
diagnosis code G93.41. Our physician reviewer found while the enrollee was reported to be unresponsive at 
home, she was indicated as at baseline mental status in the emergency department (ED). The history and 
physical indicated that the enrollee was confused and neurology notes on January 19, 2022 and January 20, 
2022 indicated that she was alert and oriented. The enrollee remained confused throughout the admission with 
no significant improvement with treatment. There was no clinical or laboratory evidence of metabolic 
encephalopathy. The review has determined that the documentation does not support the billing of diagnosis 
code G93.41.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 18, 2022, to January 22, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transport provided on August 1, 2021. 
 
You asked the Plan to pay for the air ambulance transport. You say that the medical records provided support 
the need for the air ambulance transport. The Plan denied your request. The Plan says the air ambulance 
transport was not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport. Our reviewer 
says that the air ambulance transport was not medically necessary. Our physician reviewer found the 
documentation does not support that the enrollee suffers from an illness or injury that contraindicates 
transportation by any means other than ambulance. The enrollee was stable enough for rehabilitation and a 
lower level of care while considering organ transplantation and did not require ambulance transportation. The 
enrollee was hemodynamically stable and did not require critical treatment during transport. The 
documentation does not support that the transferring hospital did not have adequate facilities to provide the 
medical services needed by 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 air ambulance tranport 
 have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance transport 
provided on August 1, 2021.