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

 
We decided that the Plan does not have to pay for practitioner services provided on Aril 5, 2022, billed with 
codes 92928-LD-XU, 93458-26-XU, 99291-24, 99292-24, 99152, and 99153. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support codes 92928, 
93458, and 99152. The Plan also says codes 99291 and 99292 were not billed with an appropriate modifier. 
Procedure code 99153 is considered bundled and not separately payable.  
 
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 codes 92928-LD-XU, 93458-26-XU, and 99152. is 
percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; 
single major coronary artery or branch, catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with 
left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, and 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the documentation does not support 
that the services billed with codes 92928 and 93458 were performed. Also, there is insufficient documentation 
to support moderate sedation billed with code 99152. 
 
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 practitioner services provided have not been met. Also, procedure codes 
99291-24 and 99292-24 were appropriately denied as they were not reported with the appropriate modifier. 
Procedure code 99153 has a status indicator B and is not separately payable. Therefore, we decided that the 
Plan does not have to pay for practitioner services provided on Aril 5, 2022, billed with codes 92928-LD-XU, 
93458-26-XU, 99291-24, 99292-24, 99152, and 99153.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan concurrently with a CT scan from the skull 
base to mid-thigh. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that this procedure is needed to guide further 
treatment decisions. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET/CT scan. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that the record indicates that the 
enrollee has a history of endometrial carcinoma. The record provided does not document that the requested test 
is being used to guide subsequent management of cancer treatment after completion of initial anti-cancer 
therapy. The elements of the coverage criteria are not satisfied. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a PET scan concurrently with a CT scan from the skull base to mid-thigh.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show the need to be seen by a 
rehabilitation doctor at least three times a week and it is not clear the enrollee can tolerate three hours of 
therapy a day. The Plan says that the services needed may be provided safely in a lower 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records does not show the need for required daily 
skilled nursing in a SNF setting. The Plan says that the services needed may be provided safely in a lower level 
of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve these services. You say that you have problems swallowing. The Plan 
denied your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental implants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018). 
 
You asked the Plan to pre-approve a Cala Trio stimulator device. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says based on the medical 
literature this device is considered experimental or investigational and has not been proven to be beneficial for 
the control of tremor. 
 
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 Cala Trio stimulator device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient evidence in the literature that this device is effective for 
the enrollee's tremor. The requested K1018 is not the standard of care for this enrollee's tremor according to 
current guidelines. 
 
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 Cala Trio stimulator device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist 
(K1018).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. You say that you cannot exist without this medication. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 pre-approve Reblozyl. Our reviewer says that you 
do not meet criteria for use of Reblozyl. Our physician reviewer found the Food & Drug Administration (FDA) 
has not approved Reblozyl for your diagnosis. The requested use is not supported by one of the major drug 
compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Reblozyl.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Entyvio. 
 You asked the Plan to pre-approve Entyvio. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Stelara and Remicade, Inflectra, or infliximab 
before it will approve Entyvio. 
 
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 Entyvio. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Entyvio. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Stelara and Remicade, Inflectra, or infliximab. 
The record does not show that these drugs would likely be less effective or have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Entyvio.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 14, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service was billed with an incorrect DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. There is no documentation describing genetic testing on a sample 
collected on the date of service at issue. 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 provided on April 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization procedures (36246, 
36247). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/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 genicular artery embolization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the requested services are considered experimental/ investigational at this 
time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization procedures (36246, 36247).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy provided from March 13, 2023, to April 11, 
2023.  
 
You asked the Plan to pay for the massage therapy. You say that the massage therapy was medically necessary 
and was prescribed by your orthopedic doctor. The Plan denied your request. The Plan says this provider is a 
licensed massage therapist and is therefore not qualified to perform massage therapy in an outpatient setting.  
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy provided from March 13, 2023, to  
April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient intravenous (IV) insulin therapy (OIVIT) services 
(96366 and 96365) provided on June 16, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services are supported as billed. The Plan 
denied your request. The Plan says these services are not medically necessary or reasonable and were not 
reported correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover outpatient intravenous (IV) 
insulin therapy (OIVIT) services.  
 We looked at the file and Medicare rules. Neither Medicare nor the Plan covers or pays for these types of items 
and services. Therefore, we decided that the Plan does not have to pay for outpatient intravenous (IV) insulin 
therapy (OIVIT) services (96366 and 96365) provided on June 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care received February 28, 
2023, through March 29, 2023. 
 
You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were not medically necessary. 
 
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 SNF care have been met. You did not 
submit the needed medical records to decide if the services were medically necessary. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) care received February 28, 2023, through 
March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25-GC billed for date of service April 
28, 2023. 
 
You asked the Plan to pay for procedure code 99213-25-GC. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says procedure code 99213-25-GC is considered 
bundled and not separately payable.  
 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 99213-25-GC has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99213-25-GC is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99213-25-GC have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99213-25-GC billed for date of service April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 17, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers 
require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on May 17, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (97530, 97112 and 97140) billed for 
date of service January 3, 2023. 
 
You asked the Plan to pay for therapeutic services. You say that these services were billed correctly. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R26.2 has an Excludes1 note in relation to R26.81. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for therapeutic services have not been met. Therefore, we decided that the Plan does not have to 
pay for therapeutic services (97530, 97112 and 97140) billed for date of service January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 13, 2022, to 
August 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
patient's hypoxic respiratory failure was clinical present and coded correctly. The Plan denied your request. The 
Plan says the diagnosis of J96.01, (Acute respiratory failure with hypoxia) is not supported by the medical 
record. As a result, a lower DRG was paid. 
 
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 diagnosis of J96.01, (Acute respiratory failure 
with hypoxia). 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 diagnosis of J96.01, (Acute respiratory failure 
with hypoxia) is not supported by the medical record. Our physician reviewer found the enrollee is an 81-year-
old male who was treated in the hospital for trauma related to an all-terrain vehicle (ATV) accident. The 
workup revealed pulmonary contusion, hemopneumothorax, and injury to the spleen, but no intracranial 
abnormalities. The physical findings revealed no acute distress, no breathing abnormalities, alert, but requiring 
low dose oxygen support, fluids, pain medication, antibiotics, and steroids. The enrollee's vitals and breathing 
status remained stable throughout the hospitalization. Based on the above, the documentation does not 
sufficiently support J96.01, (Acute respiratory failure with hypoxia) as the enrollee did not have significant 
respiratory distress, accessory muscle use, altered mental status, or hypoxia that required high flow oxygen 
support, bilevel positive airway pressure (BiPAP), or vent support. Continuous positive airway pressure 
(CPAP) was utilized but is a standard option for helping maintain positive lung pressure for pneumothorax, 
which this enrollee had.   
 
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 August 13, 2022, to August 21, 2022, at the Diagnosis Related 
Group (DRG) originally billed.