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

 
We decided that the Plan does not have to pre-approve a Stabilink MIS Interlaminar Spinal Fixation system. 
 
You asked the Plan to pre-approve a Stabilink MIS Interlaminar Spinal Fixation system. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 a Stabilink MIS Interlaminar Spinal 
Fixation system. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the stabilink system is experimental. More research is 
needed to show safety and efficacy of interlaminar devices. 
 
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 Stabilink MIS Interlaminar Spinal Fixation system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Stabilink MIS Interlaminar Spinal Fixation 
system.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for Part B drugs provided on September 29, 2020. 
 
You asked the Plan to waive the coinsurance for the Part B drugs. You say that you have never been charged 
for drugs given during a surgical procedure. The Plan denied your request. The Plan says that this cost sharing 
was charged correctly. 
 
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 forwarded the 2020 EOC. Without this contract 
information, we are unable to verify the cost share amounts applied to any services rendered in 2020. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial is not 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to waive the coinsurance 
for Part B drugs provided on September 29, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement with the dialysis facility for payment. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 14, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 
12, 2022, to April 2, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $390 
copayment per day for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted more than 5 
days, resulting in a copayment amount of $1,950 ($390 per day for 5 days = $1,950). 
 
You have been asked to pay $390 copayment per day for days 1 to 5 for inpatient hospital care. This 
item/service falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital care provided on March 12, 2022, to April 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroablation (code 64640). 
 
You asked the Plan to pre-approve neuroablation. You say that neuroablation is medically necessary. The Plan 
denied your request. The Plan says due to lack of sufficient evidence to establish evidence safety/efficacy over 
other methods, pulsed, endoscopic, cyroneurolysis, chemical, or laser ablation are considered investigational. 
 
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 neuroablation. Our reviewer says that 
the requested neuroablation is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental/investigational for post-operative knee pain. The 
request is deemed 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 neuroablation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neuroablation (code 64640).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on June 30, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that this should be paid. The Plan denied your request. 
The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 5, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the ultrasound have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on 
June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for hospital care provided 
from January 1, 2022, to January 13, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for the hospital care. You say that you did not have 
an option to choose a network facility. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $150 deductible which applies to inpatient hospital care.  
 
Your contract with the Plan also clearly says that you must pay a 4% coinsurance for inpatient hospital care, 
after the deductible is met. 
 
The item or service you asked the Plan to waive the deductible and coinsurance for falls within the inpatient 
hospital care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is $150 deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation 
that had not been met at the time the hospital care was received on January 1, 2022, to January 13, 2022. The file shows that on the date of service, you had a total of $41.19 remaining to meet your deductible. Once  this 
was met, the 4% coinsurance applied for each day of inpatient care. This means you have been asked to pay the 
correct amount based on your contract with the Plan. This is a contractual obligation you agreed to pay when 
you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the deductible and 
coinsurance for hospital care provided from January 1, 2022, to January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88112) provided on March 9, 2022. 
 
You asked the Plan to pay for the pathology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 8, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the pathology services have not been met. 
Therefore, we decided that the Plan does not have to pay for pathology services (88112) provided on March 9, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service May 21, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223. 
 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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service May 21, 2022.
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 medical records were submitted to 
support medical necessity. The Plan denied your request. The Plan says the LTACH services you are 
requesting do not meet the requirements for approval. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving 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 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 63081) provided to the enrollee on 
May 10, 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 that procedure code 63081 is not supported by the medical records 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 63081 is "Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with 
decompression of spinal cord and/or nerve root(s); cervical, single segment." 
 
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 supported by the medical records. Our reviewer found that the enrollee was being treated for 
radiculopathy of the cervical spine; cervical spondylosis with myelopathy; cervical stenosis of the cervical 
spine. She underwent a C4 partial corpectomy including C3-4 discectomy; C4-5 and C5-6 anterior cervical 
discectomy and fusion; C3-4 anterior cervical fusion; C3-6 anterior cervical instrumentation; C3-4, C4-5, and 
C5-6 insertion of intervertebral biomechanical implant; allograft on 5/10/22. The procedure notes cite the 
posterior inferior corner of C4 was resected to initiate the partial corpectomy of C4 and decompression the 
retrovertebral stenosis. The partial corpectomy was completed at C4 with resection of the posterior superior 
corner using the bur and a Kerrison rongeur to decompress the stenosis behind the vertebrae. Therefore, the 
records do support that CPT 63081 was rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 63081) provided to the enrollee on May 10, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 but requires short-term 
additional acute-care services including additional weaning that can safely be provided at the current facility 
until more stable and 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. 
 
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 the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70460 billed for date of service February 23, 
2022. 
 You asked the Plan to pay for procedure code 70460. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70460 is bundled into payment for 
code 0042T. 
 
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 70460 
is a column II code to column I code 0042T. 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 70460 billed for date of service February 23, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electroencephalogram (95822) provided on April 6, 2022. 
 
You asked the Plan to pay for the electroencephalogram. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the code 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 find that CPT code 95822 is not supported in the medical record. Specifically, records show the patient was 
awake during this procedure. Based on this information, we decided that Medicare rules for coverage of the 
electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for an 
electroencephalogram (95822) provided on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 14, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this testing was medically necessary and was 
ordered by the enrollee's provider. The Plan denied your request. The Plan says there is insufficient information 
to support the medical necessity of these services, and when contacted, the enrollee's physician denied ordering 
this test. 
 
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. 
 
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 laboratory services have been met. Specifically, the provided records do not include any progress notes or medical records from the ordering 
physician to show that this physician is treating the enrollee and to support that the requested testing was 
medically necessary and reasonable. Therefore, we decided that the Plan does not have to pay for laboratory 
services provided on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that a more complex drug screening was provided. The 
Plan denied your request. The Plan says the service is integral to the primary procedure. 
 
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. We find that the testing described by the billed code is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab services provided on August 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services, provided on March 22, 2022, 
through March 30, 2022. 
 
You asked the Plan to pay for the home health services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the member was enrolled in a federal hospice program during the time 
services were rendered. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. Original Medicare continues to pay 
for services furnished after the revocation or expiration of the enrollee's hospice election until the first day of 
the month after the hospice election has been revoked or terminated. The rules say that the Plan may direct the 
provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the home health services, provided on March 22, 2022, 
through March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic testing provided on June 29, 2021. 
 
You asked the Plan to pay for cardiovascular genetic testing. You say that this test was medically reasonable 
and necessary. The Plan denied your request. The Plan says cardiovascular genetic testing is not a covered 
screening under Medicare and was not medically necessary in this case. 
 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, cardiovascular genetic 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 cardiovascular genetic testing provided on June 29, 2021.