Persius/hicric huggingface dataset:
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 requires comprehensive 
wound care, pain management, and daily physician assessment. The Plan denied your request. The Plan says 
the LTACH services requested 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 is receiving acute hospital care, and acute care services have not been 
denied. The documentation shows there are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from October 4, 2022 to October 31, 
2022 
 
You asked the Plan to pay for the services. 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 February 2, 2023. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided from October 4, 2022 to October 31, 
2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is indicated for the enrollee. The Plan 
denied your request. The Plan says this 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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term outcomes to 
establish the value of CardioMEMS in patient management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37253, 75625-59, and 75716-59 billed for 
date of service February 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that the code is supported in the medical records. 
The Plan denied your request. The Plan says the codes remain 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 37253 is intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure).  
The definition of code 75625 is aortography, abdominal, by serialography, radiological supervision and 
interpretation. We find that codes 37253 and 75625 are not supported in the medical record as billed.  
 
The definition of code 75716 is angiography, extremity, bilateral, radiological supervision and interpretation. 
We find that angiography services are included in code 37225. 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 codes 37253, 75625-59, and 75716-59 billed for date of service February 6, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service July 29, 
2022.

You asked the Plan to pay for procedure code 81345. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 
0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service July 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) for 9 additional months. 
 
You asked the Plan to pre-approve a home ventilator. You say that you have been on the ventilator because you 
have COPD. You also say that you cannot breathe on your own, and your life would be at risk without the 
machine. The Plan denied your request. The Plan says this request does not meet the requirements for approval. 
 
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 for 9 additional 
months. Our reviewer says that a home ventilator (E0466) for 9 additional months is not medically reasonable 
and necessary. Our physician reviewer found the provided records in this case document a diagnosis of chronic 
respiratory failure consequent to COPD and obstructive sleep apnea. The records document that the home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
expiratory positive airway pressure (EPAP) which could be provided by a bilevel positive airway pressure 
(BiPAP) device with AVAPS and a back-up rate. Our reviewer found that the provided records do not 
document trial and failure of a BiPAP device with AVAPS and a back-up rate. Our physician reviewer also 
found that the records in this case do not provide adequate detailed information to meet Medicare criteria for 
coverage of a ventilator as opposed to 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 for 9 additional months have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a home ventilator (E0466) for 9 additional months.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798-XU billed for date 
of service October 14, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798-XU. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these services 
are not supported for separate reporting in this case. 
 
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 87481, 87653, and 87798-XU are column II codes to column I code 
87801. Procedure codes 87481 and 87653 have not been billed with an appropriate modifier to bypass the edit. 
Based on the claim submitted, Medicare billing criteria have not been met for codes 87481 and 87653. 
However, code 87798-XU was billed with a modifier.  
 
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 procedure code 87798-XU. Our reviewer says that the XU 
modifier is not supported for this code. Our reviewer found that the laboratory report does not include 
documentation to support an unusual non-overlapping service. This procedure would be included in CPT 
87801, and modifier XU cannot be verified by the documentation submitted for review. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87653, and 87798-XU have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798-XU billed for date 
of service October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home ventilator is being requested for use in a volume assured pressure support mode (TTV-VAPS) with auto-EPAP 
(AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with average volume-
assured pressure support (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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via Disc NP (0627T). 
 
You asked the Plan to pre-approve Via Disc NP. 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 Via Disc NP. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Via disc is experimental for back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Via Disc NP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Via Disc NP (0627T).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pay for and waive the copayment for neurosurgeon services and a hospital stay provided 
in the Republic of Ecuador from June 17, 2022, to June 19, 2022. You say that you should be reimbursed for 
these services. The Plan says that the Plan has not paid for the neurosurgeon's fee on June 17, 2022, and you 
are responsible for a $125 copayment for emergency care. 
 
We decided that the Plan has to pay for neurosurgeon services.  
 
The Plan follows Medicare rules. Medicare rules state that items and services furnished outside of the United 
States and its territories are not covered except under limited, specified circumstances. The Plan offers a worldwide coverage benefit that goes beyond Medicares coverage. For that reason, the Plans rules apply to 
this case. The Plan covers emergency care services worldwide except for transportation. You must submit 
proof of payment, translations, and currency conversions upon claim submission. 
 
You received neurosurgeon services on June 17, 2022 for the purposes of hematoma evacuation for a 
hematoma of the brain. We decided that this service does meet criteria for emergency care. A prudent 
layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical 
care to seriously jeopardize their health in this case. You submitted proof of payment in the amount of $1,500 
USD and translations. There is no need for currency conversion because you paid for this service directly in 
USD. Therefore, this claim has met all of the Plans criteria for payment. Therefore, we decided that the Plan 
has to pay for neurosurgeon services.  
 
We also decided that the Plan does not have to waive the copayment for hospital stay. 
 
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 $125 
copayment for worldwide emergency care.  
 
You have been asked to pay $125 copayment for emergency care. This item/service falls within the Emergency 
Care (Worldwide) 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 pay for and waive the copayment for hospital 
stay. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that Prolia is a necessity for your care. The Plan denied your 
request. The Plan says step-therapy rules for coverage of Prolia have not been met. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial 
of an intravenous bisphosphonate before they will approve the requested drug. You have age-related 
osteoporosis without osteoporotic fracture. The requested drug is a new start. The provided records do not 
indicate that you have tried and failed the Plan's preferred step-one alternatives. The record does not indicate 
that you have a contraindication to, or would have an adverse effect from, the Plan's preferred step-one 
alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service November 14, 
2022, to November 15, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 14, 2022. The NOA was not received by the Plan within five 
days. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service November 14, 2022, to November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on January 27, 2023. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
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 describe 
colonoscopy procedures provided with sedation. There is a more appropriate Healthcare Common Procedure 
Coding System (HCPCS) code to report for sedation when performed with gastrointestinal-endoscopy 
procedures. Of note, CPT 99152 is not supported in the medical record as a distinct procedural service. 
Therefore this service denied correctly. 
 
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 moderate sedation services (procedure code 99152) rendered on January 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 77062. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services identified with code 87636 for date of 
service December 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
identified with code 87636 for date of service December 1, 2022.