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

 
We decided that the Plan has to pay for the medical services provided from February 2, 2023, through February 
8, 2023. 
 
You asked the Plan to pay for the medical services. You say that you were told after your knee-replacement 
surgery on November 21, that your office visits for the next 90 days are covered under the surgery at 100 
percent, but they did not disclose to you that the injection you had on this claim is not inclusive to the 90 days. 
You state the provider also submitted the bill to the Plan as an outpatient hospital procedure even if it was only 
an office visit. The Plan denied your request. The Plan says that the claim was processed accordingly with your 
2023 EOC benefits. 
 
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 did not substantiate their denial. An Explanation of Benefits (EOB) and 
medical documentation was not provided to verify if the services were included in a global surgical package. 
Therefore, we decided that the Plan has to pay for the medical services provided from February 2, 2023, 
through February 8, 2023.  
 
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 procedure code(s) 85060 billed for date of service October 6, 
2022. 
 You asked the Plan to pay for procedure code(s) 85060. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. This means no 
TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, 
generally through the Hospital Fee Schedule payment rate. No payment is recognized for CPT code 85060 
furnished to hospital outpatients or non-hospital patients. Based on this information, we decided that Medicare 
rules for coverage of procedure code 85060 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code(s) 85060 billed for date of service October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88112, 88305, 88312 and 88361 billed for 
date of service April 25, 2022. 
 You asked the Plan to pay for procedure code(s) 88112, 88305, 88312 and 88361. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88112, 88305, 88312 
and 88361. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88112, 
88305, 88312 and 88361. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88112, 88305, 88312 and 88361 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88112, 88305, 88312 and 88361 billed for date of service April 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable X-ray services provided on January 18, 2023. 
 
You asked the Plan to pay for portable X-ray services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if the mobile unit is serving an entity for which 
another POS code already exists, providers should use the POS code for that entity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of portable X-ray services have not been met. Specifically, the services at issue have been reported with POS code 11, indicating an outpatient office setting. The case record does not support that the services at 
issue were rendered in an outpatient office setting. Therefore, we decided that the Plan does not have to pay for 
portable X-ray services provided on January 18, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous immunoglobulin (IVIG) (J1569). 
 You asked the Plan to pre-approve IVIG. You say that the enrollee has trialed several medications, including 
mycophenalate, clonazepam and baclofen. You also say that there is evidence to validate the role of IVIG in 
Stiff-person syndrome management in patients not responsive to or intolerant of benzodiazepines as 
monotherapy or in combination with baclofen. The Plan denied your request. The Plan says the information 
received does not show that the enrollee has been treated with any of the formulary medications, and this 
request cannot be approved. 
 
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 IVIG. Our reviewer says that the 
enrollee does not meet the coverage criteria for IVIG. Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred 
step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IVIG have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intravenous immunoglobulin (IVIG) (J1569).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 14, 2022, to 
April 12, 2022. 
 You asked the Plan to pay for the home health services. You say that you were not aware that the Plan was 
going to require NOAs.  You said that as soon as you learned a NOA was required, it was submitted. 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 12, 2021. The NOA was not received by the Plan until July 12, 
2022. 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 home health services provided 
from March 14, 2022, to April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for 
admission to an IRF.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 5, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. 
 
We looked at the file and Medicare rules. The record shows that the claim was billed with diagnosis code 
J12.82. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. 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 the services provided on January 5, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant 360 CDx testing (0326U) provided on February 6, 2023. 
 
You asked the Plan to pay for the Guardant 360 CDx testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says that a signed and dated test requisition and test results are needed 
to approve this request. 
 
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. In this case the Plan indicated that the claim was denied because a signed and 
dated test requisition and test results were required. These items are included in the case file. The Plan has not 
provided any other reason for denial. Therefore, we decided that the Plan has to pay for the Guardant 360 CDx 
testing (0326U) provided on February 6, 2023.  
 
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 genetic testing provided on February 2, 2023, billed with 
codes 81216, 81238, 81242, 81249, 81279, 81298, 81317, 81321, 81339 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 2, 2023, billed with codes 81216, 81238, 81242, 81249, 81279, 81298, 81317, 81321, 81339 and 
81345.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a follow-up sleep study (95810 and 95811). 
 
You asked the Plan to pre-approve a follow-up sleep study. The Plan denied your request. The Plan says the 
medical documentation does not support another sleep study and patient should be referred to see a sleep 
specialist.  
The Plan follows Medicare rules. Medicare rules say that a follow-up polysomnography or a cardio-respiratory 
sleep study is indicated for the conditions listed in the Medicare rules section of this letter. 
 
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 follow-up sleep study. Our reviewer 
says that a polysomnography is not medically necessary. Our physician reviewer found the enrollee has a 
diagnosis of obstructive sleep apnea, based on polysomnography from February 2021. The apnea-hypopnea 
index (AHI) was 11.7. The enrollee has been treated with auto-titrating CPAP. Our reviewer found that the 
medical records indicate the enrollee is having sleep issues, but there is no complete sleep history or 
assessment of daytime sleepiness. A compliance report covering May 10, 2023, to June 8, 2023, shows use of 
the device at least 4 hours per day for 63% of days. Our physician reviewer found that this does not meet 
minimum Medicare requirements of at least 70% of days. The AHI on the device is 1.3, suggesting it is 
effective. Our reviewer also found that the enrollee may benefit from a sleep consultation and increased 
consistency with CPAP use. 
 
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 follow-up sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a follow-up sleep study (95810 and 95811).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk and require IRF services to 
regain your prior level of functioning. The Plan denied your request. The Plan says that the request is not 
medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that you have complex nursing and rehabilitation needs. The medical record supports a need for physical 
and occupational therapy. Additionally, there a reasonable expectation that you will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
 
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 the facet injection provided on December 12, 2022. 
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says the services were not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a 
time period, which includes all procedures (i.e., medial branch block (MBB), intraarticular injections (IA), 
facet cyst ruptures, and RFA ablations that are performed during the same day. 
 
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 injection. Our reviewer says that the requested injection was not medically reasonable and necessary. Our physician reviewer found that the 
utilization limit is 2 levels bilaterally. There are no unique circumstances that indicated the need for 3 levels of 
diagnostic blocks. Therefore, the third level was not medically reasonable and 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the facet injection provided on December 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Euflexxa injection in the right knee (J7323). 
 
You asked the Plan to pre-approve the injection. You say that this service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for this service to be covered, there must be a 
radiological exam to support the clinical diagnosis of osteoarthritis of the knee will be available in the patients medical record. 
 
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 injection. Our reviewer says that the 
requested injection is not medically necessary. Our physician reviewer found there is no documentation of 
radiologic images showing osteoarthritis of the right knee. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Euflexxa injection in the right knee (J7323).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from an IRF level of care 
to remain under physician oversight while working intensively with physical therapy, occupational therapy, and 
speech therapy services to address function and self-care deficits and decline, and to maximize their level of 
independent functioning. The Plan denied your request. The Plan says admission to an IRF is not medically 
necessary.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.