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

 
We decided that the Plan does not have to pay for drug testing services (G0480, 80307 and 83789) provided on 
June 7, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported in the 
provided records. The Plan denied your request. The Plan says there is insufficient information to determine if 
these services were medically necessary. In addition, specimen validity testing (83789) is not separately 
payable as it is included in the payment for presumptive and definitive drug tests. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules say that while a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent for the testing to be performed. Tests 
which are not ordered by the physician who is treating the enrollee are not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, the physician signature on the laboratory order is illegible and no progress notes or medical 
records were provided to support the medical necessity of these services. Therefore, we decided that the Plan 
does not have to pay for drug testing services (G0480, 80307 and 83789) provided on June 7, 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 
February 1, 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 February 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on April 28, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations.  
The Plan must follow Medicare rules. Medicare rules say that home health agencies (HHAs) shall no longer 
submit Requests for Anticipated Payment (RAPS -Type of Bill 0322) for any HH period of care with a From 
date on or after January 1, 2022. 
 
We looked at the file and Medicare rules. In this case, the type of bill submitted was 0322 for services rendered 
after January 1, 2022. Based on this information, we decided that Medicare rules for coverage of the home 
health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided on April 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Diclofenac 3% gel. 
 
You asked the Plan to pre-approve Diclofenac. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have 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 drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Diclofenac 
3% gel.  
 Benefits for Diclofenac 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 23, 2021 to May 
26, 2021, 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 this 
service was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
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 a secondary diagnosis of J96.01. 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 billed DRG is not supported by the records. Our physician reviewer found the 
patient did not require high flow oxygen or BiPAP to meet the criteria for acute respiratory failure.  
 
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 May 23, 2021 to May 26, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service January 4, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says the payment for code 93042 is included in the payment 
for code 99291. 
 
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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not payable. 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 93042 billed for date of service January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft, morselized, or placement of osteopromotive 
material, for spine surgery only (20930). 
 
You asked the Plan to pre-approve allograft. You say that the requested service is 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 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 allograft. Our reviewer says that the 
requested allograft is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation does not indicate that osteopromotive allograft is not medically needed in 
this case. Therefore, the reviewer found that the requested allograft 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 allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve allograft, morselized, or placement of osteopromotive material, for spine surgery only (20930).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (U0003) provided on November 8, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that this service was necessary and should be paid. 
The Plan denied your request. The Plan says that this service has already been paid in another claim for this 
enrollee. 
 
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 sufficient evidence that the enrollee was 
in a skilled nursing facility at the time of services, and the Plan has provided no other claim form or 
documentation of payment to show that this service has already been billed by and paid to another entity. 
Therefore, we decided that the Plan has to pay for laboratory testing (U0003) provided on November 8, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be performed at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intra-osseous basivertebral nerve ablation to L5-S1. 
 
You asked the Plan to pre-approve intra-osseous basivertebral nerve ablation to L5-S1. You say that intra-
osseous basivertebral nerve ablation to L5-S1 is medically necessary. The Plan denied your request. The Plan 
says intra-osseous basivertebral nerve ablation to L5-S1 is not medically necessary. 
 
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 intra-osseous basivertebral nerve 
ablation to L5-S1. Our reviewer says that the requested intra-osseous basivertebral nerve ablation is not 
considered medically reasonable and necessary. Our physician reviewer found that this is an experimental/ 
investigational procedure. Therefore, the request is considered 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 intra-osseous basivertebral nerve ablation to L5-S1 have not been met.  Therefore, we decided that the Plan does not have to pre-approve intra-osseous basivertebral nerve ablation to 
L5-S1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this service is medically necessary. The Plan 
denied your request. The Plan says experimental procedures are non-covered. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found The Intracept procedure is experimental. More research is needed to show safety and efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on November 22, 2021, and November 
23, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered for 
the enrollee's diagnosis. 
 
The Plan follows Medicare rules. Medicare rules say that cytogenetic testing is only covered for the indications 
established in the applicable NCD. 
 
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 testing. Our reviewer says that the requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of Diffuse B-cell lymphoma of lymph nodes in multiple regions. Given the diagnosis, 
the requested testing is not medically reasonable or necessary according to the coverage indications in the 
NCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the testing provided on November 22, 2021, and November 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for various vascular services provided to the enrollee on April 7, 
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation  
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found CPT 75625 and CPT 75710 code for 
supervision and interpretation, diagnostic angiography of the aorta and unilateral extremity respectively. The 
work for these codes is bundled into the procedure code for atherectomy with or without angioplasty that has 
already been billed and covered. The exception to this is if there was no prior imaging study or if that study 
was inadequate or there was a significant change in condition. In this case, the patient underwent diagnostic 
aortography and right lower extremity angiography less than 6 months prior. There is no documentation 
provided demonstrating that there has been a substantial change in condition since that prior study. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for various vascular services provided to the enrollee on April 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tecartus. 
 
You asked the Plan to pay for Tecartus. The Plan denied your request. The Plan says this drug is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tecartus. Our reviewer says that Tecartus is 
not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that 
the enrollee has a diagnosis of relapsed mantle cell lymphoma with central nervous system involvement. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. 
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecartus have not been met. Therefore, we decided that the Plan does not have 
to pay for Tecartus.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and electronic 
connection (E2311). 
 
You asked the Plan to pre-approve the wheelchair accessories.. The Plan denied your request. The Plan says 
these services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a 
wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of 
the connection is for a power seat elevation or power standing feature, it will be denied as non-covered.  
 
We looked at the file and Medicare rules. The requested accessories are not covered per LCA A52504. Based 
on this information, we decided that Medicare rules for coverage of the wheelchair accessories. have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) 
and electronic connection (E2311).
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. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility (SNF). 
 
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 enrollee was admitted for surgical management of a hip fracture after a fall. The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a continuous glucose monitor (K0553, 
K0554). 
 
You asked the Plan to waive the copayment for the continuous glucose monitor. You say that the continuous 
glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to waive 
the copayment for a continuous glucose monitor (K0553, K0554).