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

 
We decided that the Plan does not have to pay for physician services (99212) provided on May 4, 2022 to May 
5, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this code cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99212 is Office or other outpatient visit for the evaluation 
and management of an established patient. 
 
We find that CPT code 99212 is not supported in the medical record. Specifically, this service was billed with 
an inpatient place of service (21), however records show the enrollee was an outpatient. Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99212) provided on May 4, 
2022 to May 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug services billed with code J3490 on 
April 29, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure 64484. Payment for code J3490 is included in the global surgical payment for code 
64484. Therefore, we decided that the Plan does not have to pay for the unclassified drug services billed with 
code J3490 on April 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arterial catheterization or cannulation for sampling, 
monitoring or transfusion (separate procedure); percutaneous provided to the enrollee on July 15, 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 Current Procedural Terminology (CPT) code 36620 remains 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 36620 is "Arterial catheterization or cannulation for 
sampling, monitoring or transfusion (separate procedure); percutaneous." 
 
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 that the medical records provided 
does not include sufficient documentation to validate that this code was rendered in this case. The procedure 
cannot be verified. 
 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 arterial catheterization or cannulation for sampling, monitoring or transfusion (separate 
procedure); percutaneous provided to the enrollee on July 15, 2022.
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. The Plan denied your request. The Plan says the enrollee's current 
level of function does not require an intensive, complex, multidisciplinary approach to daily therapy. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
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 enrollee requires an Acute Rehabilitation Facility 
to return to prior level of function. The Plan denied your request. The Plan says the enrollee's records do not 
show the need for a full time access to a doctor or skilled rehabilitation nurse and are currently at baseline for 
activities of daily living these needs can be met at an alternate 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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D testing (82306) provided on September 2, 
2022. 
 You asked the Plan to pay for the Vitamin D testing. You say that this service should be covered. The Plan 
denied your request. The Plan says screening tests are not covered. 
 
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, the Vitamin D testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the Vitamin D testing (82306) provided on September 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A0425 billed for date of service October 12, 2022. 
 
You asked the Plan to pay for code A0425. You say that it was medically necessary to send the patient to 
another hospital. The Plan denied your request. The Plan says you billed too many units of this code on a single 
line item. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has Medically Unlikely Edits for 
ambulance mileage.  This MUE is the maximum number of units for the billed code per line.  The MUE for 
code A0425 is 250 units on a single line. If you report this code with units greater than the MUE assigned, the 
line or the claim will deny. In this case, you billed 378 units of code A0425 on a single line of the claim.  
Because this is in excess of the 250-unit MUE, you would have needed to bill the excess units on a separate 
line of the claim.. Therefore, we decided that the Plan does not have to pay for code A0425 billed for date of 
service October 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sure injection. 
 
You asked the Plan to pre-approve Repatha Sure. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the requested drug is not covered under Medicare Part B. 
 
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 Repatha Sure injection.  
 Benefits for Repatha Sure 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 COVID-19 test received on September 20, 2022. 
 
You asked the Plan to pay for the COVID-19 test. You say that this test was a requirement to board a celebrity 
cruise ship the following day. The Plan denied your request. The Plan says the services received are not a 
covered 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 COVID-19 test at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
COVID-19 test received on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided for use during 
surgery on August 31, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was provided for use 
during surgery to prevent thrombotic events. The Plan denied your request. The Plan says this device was 
provided for a non-covered purpose. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device provided for use during surgery on August 31, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services received on January 5, 2022. 
 
You asked the Plan to pay for the services. You say that as far as you understand, you have paid everything that 
is owed, and you never have received an Explanation of Benefits (EOB) to the contrary. The Plan denied your 
request. The Plan says that the case was autoforwarded for an untimely plan response. 
 
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. The plan has not forwarded any clear reason for why these services have been 
denied. The plan has not clearly verified if you still owe any money for these services. Therefore, we decided 
that the Plan has to pay for imaging services received on January 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for short-latency somatosensory evoked potential study, 
stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or 
head provided to the enrollee on March 24, 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 code 95927 is "Short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the 
trunk or head." 
 
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 that the enrollee was noted to have 
had surgery, and intraoperative neuromonitoring (IONM) services were provided. However, the records provided for review did not reflect that recording was performed as defined by CPT code 95927. Rather, the 
technical and physician reports only supported stimulation from the limbs which was more appropriately coded 
by 95938 (and reimbursed). In this setting the CPT code billed cannot be said to have been supported by the 
records. 
 
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 short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or 
skin sites, recording from the central nervous system; in the trunk or head provided to the enrollee on March 
24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on March 30, 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 Current Procedural Terminology (CPT) code 95822 26 (1 Unit) remains not supported, as the 
code is not appropriate for the service 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 code 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 that the code is not supported as the 
enrollee was not in a coma or sleep. There are more appropriate codes to use in this clinical scenario. 
 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 electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on 
March 30, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
provided to the enrollee on June 3, 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 billed service line 99285 was not supported in the medical documentation submitted. 
 
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 a medically appropriate history and/or examination and high level 
of medical decision making." 
 
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 that the enrollee presented to the 
emergency department (ED) with an eye injury following an assault. The enrollee was found to have some 
bruising and one small 2cm laceration over the left lateral eyebrow. Otherwise, the exam was unremarkable. The workup was negative, including the computed tomography (CT) of the head/chest. Vitals were stable. 
Based on the documentation for this ED visit, there was no description of a need for high complexity decision 
making to meet the requirements for CPT 99285. 
 
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 emergency department services (procedure code 99285) provided to the enrollee on June 3, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing of 15-21 classes (G0482) provided on 
September 20, 2022. 
 
You asked the Plan to pay for the definitive drug testing of 15-21 classes. You say that this testing should be 
covered as billed. The Plan denied your request. The Plan says that only 8 drug classes were tested. 
 
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 G0482 is the definitive testing of 15-21 drug classes. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, we reviewed the claim and 
confirmed that 15-21 classes of drugs were tested. Based on this information, we decided that Medicare rules 
for coverage of the definitive drug testing of 15-21 classes have been met. Therefore, we decided that the Plan 
has to pay for the definitive drug testing of 15-21 classes (G0482) provided on September 20, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that Zilretta is medically necessary. The Plan denied your 
request. The Plan says a trial of a triamcinolone acetonide intra-articular injection is required before 
alternatives can be considered. 
 
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 Zilretta. Our reviewer says that Zilretta 
is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs 
or any reason they would be unsafe or ineffective for this 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on August 20, 
2022, to September 22, 2022. 
 
You asked the Plan to pay for the CXbladder detect test. You say that you disagree with this denial. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXbladder detect test have not been met. Therefore, we 
decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on August 20, 2022, 
to September 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0422, A0425, A0428) provided on 
October 17, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the ambulance services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that once a member is admitted to an Inpatient 
Hospital or Critical Access Hospital (CAH), it may be necessary to transport the member to another hospital or 
other site temporarily for specialized care while the member maintains inpatient status with the original 
provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient 
hospital or CAH service. 
 
We find that CPT codes A0422, A0425, & A0428 are not supported in the medical record. Specifically, the 
records show the enrollee was an inpatient at the time the transportation was provided. These services must be 
billed by the hospital as patient transportation. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services (A0422, A0425, A0428) provided on October 17, 2022.