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

 
We decided that the Plan does not have to pay for the laboratory services (U0004, U0005, 99001) provided 
December 1, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that these codes come under the Public Health 
Emergency extension. Please check the attachment and consider this and process the claim accordingly. The 
Plan denied your request. The Plan says the claim was submitted after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory service was not filed until June 19, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (U0004, U0005, 99001) provided 
December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection 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 the injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that there is no 
documentation of concordant radiological image-based diagnostic testing that supports thoracic radiculopathy, 
radicular pain, or neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis. Therefore, the enrollee does not meet 
the LCD coverage criteria. 
 
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 an epidural steroid injection.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve the Prolia. 
 
You asked the Plan to pre-approve the Prolia. You say that the drug should be covered. The Plan denied your 
request. The Plan says that the enrollee did not meet the step therapy requirements. 
 
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 submit any of the medical records they reviewed in order to 
make their determination. Therefore, we decided that the Plan has to pre-approve the Prolia.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says these services can the enrollee needs can be provided 
safely in an alternate setting.  
 
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 enrollee does not require intensive or complex rehabilitation services and does 
not require admission to the acute inpatient rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met.  
 
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 enrollee is functioning at a standard post-acute care level routinely managed at a 
level of care other than an IRF. The enrollee does not require complex or intensive rehabilitation services and 
does not require frequent physiatry oversight.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cyanocobalamin and levocarnitine provided on July 5, 
2023. 
 
You asked the Plan to pay for the medications. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says experimental and investigational procedures are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pay for the medications. Our reviewer says that the 
requested medications are not medically necessary. Our physician reviewer found the enrollee has a history of 
bilateral lower extremity pain. The clinical value and effectiveness of levocarnitine and cyanocobalamin in the 
setting of lower leg pain have not been demonstrated in the peer-reviewed literature. The documentation does 
not support that the cyanocobalamin and levocarnitine are safe and effective 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 the medications have not been met. Therefore, we decided that the Plan does 
not have to pay for the cyanocobalamin and levocarnitine provided on July 5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that the medication is detrimental to mental health and 
wellbeing of the enrollee and decompensation. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Spravato.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing home visit provided on May 8, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the nursing home visit. You say that your company has an exclusive contract 
with the nursing home. The Plan denied your request. The Plan says the initial decision to deny payment for 
out-of-network services without authorization was correct. 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a nursing home visit provided on May 8, 2023, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for  rotary wing air transport (A0431) and rotary wing air mileage (A0436) 
provided on November 18, 2022. 
 
You asked the Plan to pay for rotary wing air transport (A0431) and rotary wing air mileage (A0436). You say 
that the rendered services were medically necessary. The Plan denied your request. The Plan says that this does 
not meet the medical necessity criteria for an overturn. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 rotary wing air transport (A0431) and rotary 
wing air mileage (A0436). Our reviewer says that the service is medically necessary and appropriate. Our 
physician reviewer found the enrollee required transfer for higher level of care, which was not available at the 
sending hospital. Our physician reviewer also found that the enrollee was an intensive care unit (ICU) level 
patient and did require emergent transportation, and was at high risk for rapid decompensation resulting in 
permanent disability and even death. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rotary wing air transport (A0431) and rotary wing air mileage (A0436) have 
been met. Therefore, we decided that the Plan has to pay for  rotary wing air transport (A0431) and rotary wing 
air mileage (A0436) provided on November 18, 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: 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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the services the enrollee requires can be provided safely 
in their current setting. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee cannot care for themselves due to a 
brain injury. You say that the enrollee needs a caretaker due to their limited brain function. The Plan denied 
your request. The Plan says a SNF admission is not medically necessary.  
 
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 that 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 or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 14301, 14302, 13132, and 13133 billed for 
date of service October 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes are 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 14301 adjacent tissue transfer or rearrangement, any area; 
defect 30.1 square centimeters (sq cm) to 60.0 sq cm. The definition of code 14302 is adjacent tissue transfer or 
rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for 
primary procedure). We find that code 14301 is not supported. The records do not document the defect size for 
the adjacent tissue rearrangement. We have confirmed that code 14302 is an add-on code. Because the primary 
code is not payable in this case, the add-on code is not payable. 
  
The CPT Code Manual definition of code 13132 is repair, complex, forehead, cheeks, chin, mouth, neck, 
axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm. The definition of code 13133 is repair, complex, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List 
separately in addition to code for primary procedure). We find that code 13132 is not supported. This code is 
used for wounds between 2.6-7.5 cm. The records only show the length of the complex closure, 40 cm in 
length. We have confirmed that code 13133 is an add-on code. Because the primary code is not payable in this 
case, the add-on code is not payable. 
 
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 14301, 14302, 13132, and 
13133 billed for date of service October 11, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99213-25 and 95018. We decided that the Plan does not have to pay for 
95076.  
 
You asked the Plan to pay for practitioner services provided on July 20, 2022, billed with procedure codes 
99213-25, 95018, and 95076. You say that the claim is billed correctly and should be paid. The Plan says that 
documentation does not support the billed codes. 
 
We decided that the Plan has to pay for 99213-25 and 95018.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
We asked our coding 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 practitioner services provided. Our 
reviewer says that documentation partially supports the billed codes. Our physician reviewer found that there is 
documentation to support codes 99213-25 and 95018 as these services were performed. Code 95076 is an 
ingestion allergy test that was not performed.  
 
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 been met. Therefore, we decided that the 
Plan has to pay for 99213-25 and 95018.  
 
We also decided that the Plan does not have to pay for 95076. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
We asked our coding 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 95076. Our reviewer says that 
documentation partially supports the billed codes. Our physician reviewer found that there is documentation to 
support codes 99213-25 and 95018 as these services were performed. Code 95076 is an ingestion allergy test 
that was not performed.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95076 have not been met. Therefore, we decided that the Plan does not have to 
pay for 95076. 
 
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 office visit provided on September 14, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says an explanation of benefits from the member's primary insurance carrier is needed 
before this claim can be considered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the office visit until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 billed for April 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 87506 is 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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, the records show that 27 
targets were tested and there is a more appropriate code for the services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 87506 billed for April 20, 2022.