Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to still be unstable and requires additional acute care services 
that can safely be provided at the current facility until more stable and appropriate for transfer. The enrollee 
does not require services at the LTACH that are not already available at the current facility. Completion of 
treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (93000, 96360, 96361, 96374, 96375, 
A4208, A4209, A4649, A4556, 96376) provided on April 30, 2023. 
 
You asked the Plan to pay for the outpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT codes93000, 96360, 96361, 96374, 96375, A4208, A4209, A4649, A4556, & 96376 are not 
supported in the medical record. Specifically, codes 93000, 96360, 96361, 96374, & 96375 are incident to 
codes and not separately payable. These codes are not separately billable in place of service 23 (emergency 
room). Codes A4208, & A4209 have a Medically Unlikely Edit (MUE) of 0 and are therefore non-payable. 
Codes A4649, & A4556 have a status indicator of "P" and are not separately payable. Code 96376 is an add-on code and the required primary procedure was not approved. Based on this information, we decided that 
Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for outpatient services (93000, 96360, 96361, 96374, 96375, A4208, A4209, A4649, 
A4556, 96376) provided on April 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the annual wellness visit rendered on
September 26, 2022.

You asked the Plan to waive the coinsurance for these services. You say that you should have no cost sharing
for the services. The Plan denied your request. The Plan says this cost sharing was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for out-of-network annual wellness visit at a primary care physician (PCP)'s office.

Review of the file shows that you had an annual wellness visit with an out-of-network provider on September
26, 2022. You have been asked to pay a 20% coinsurance for these services. This item/service falls within the
out-of-network annual wellness visit at a primary care physician (PCP)'s office benefit category. This means
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the coinsurance for the annual wellness visit rendered on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided on May 26, 2023. 
 
You asked the Plan to pay for the medical supplies. You say that these supplies were medically necessary. The 
Plan denied your request. The Plan says you need to first file your claim with the enrollee's primary insurer. 
 
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 provided you 
with the name of the enrollee's primary insurer, and the Plan has directed you to bill the primary insurer.  The 
Plan has made this request from you ten different times with no response. As the secondary insurer, the Plan 
cannot be held responsible for the medical supplies until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for medical supplies provided on May 26, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29530 rendered on May 25, 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 29530 is "Strapping; knee." 
 
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 in this case, strapping provided 
during a therapy program should be included in the therapeutic modality that is being provided and should not 
be billed separately.  
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 procedure code 29530 rendered on May 25, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zirabev, paclitaxel and carboplatin. 
 
You asked the Plan to pre-approve the medications. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that the requested use of this drug combination is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medications. Our reviewer says that 
the requested combination is FDA approved for the enrollees diagnosis. Our physician reviewer found that the 
combination is also supported by one of the major drug compendia or by clinical research. The request is 
reasonable and necessary given the concern for metastatic cancer from gynecological origin. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Zirabev, paclitaxel and carboplatin.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a NALU peripheral nerve stimulator. 
 
You asked the Plan to pre-approve a NALU peripheral nerve stimulator. 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 follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all conditions have been met. 
 
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 NALU peripheral nerve stimulator. 
Our reviewer says that the services are not medically necessary Our physician reviewer found this is considered 
experimental therapy and is the subject of ongoing clinical trials. Therefore, the request is deemed 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 a NALU peripheral nerve stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a NALU peripheral nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide.  
 
You asked the Plan to pay for a stair glide. You say that you believed the Plan would pay for a percentage of 
this item. The Plan denied your request. The Plan says stair glides/lifts are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on July 11, 2023, billed with 
codes 87481, 87491, 87500, 87563, 87640, 87640, 87653 and 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly 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 a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on July 11, 2023, billed with codes 87481, 87491, 87500, 87563, 87640, 87640, 87653 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99306 billed for date of service March 22, 2023. 
 
You asked the Plan to pay for code 99306. You say that this code was billed accurately. The Plan denied your 
request. The Plan says the medical records do not support the billing of code 99306. The records don't support a 
high level of medical decision making or the total time required of the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99306 is initial nursing facility care. per day, for the 
evaluation and management of a patient, which requires these three key components: a comprehensive history; 
a comprehensive examination; and medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of high severity.  Typically, 45 minutes are spent at the bedside and on the patient's facility floor or unit.  
 
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 code 99306. Our reviewer says that code 99306 is not 
supported by the medical record. Our reviewer found this case pertains to a 76-year-old female who was 
admitted to an acute rehabilitation facility after falling and suffering orthopedic injuries. At issue is 
documentation supporting billing code 99306. The documentation does not support a high level of medical 
decision-making, nor does it support a comparable time-based effort. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99306 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99306 billed for date of service March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transplantation medicine, quantification of donor-derived 
cell-free DNA using whole genome next-generation sequencing (0118U) provided October 7, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that you request the Plan overturn the decision 
made during previous processing of this claim and reprocess this service at in-network cost sharing. The Plan 
denied your request. The Plan says medical necessity cannot be established. 
 
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 the laboratory testing have been met. 
Additional records were requested to be able to determine the medical necessity of this service. The records 
show that the Plan made multiple attempts without success. Therefore, we decided that the Plan does not have 
to pay for the transplantation medicine, quantification of donor-derived cell-free DNA using whole genome 
next-generation sequencing (0118U) provided October 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and 
reporting (20611 - 2 units) provided September 15, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording 
and reporting.  
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The provider reported CPT 20611LT 2 units. The documentation 
describes injection with ultrasound guidance for right and left shoulder. In this case, the service was incorrectly 
reported, as injections were performed bilaterally, but left was reported with 2 units. Therefore, services were 
incorrectly reported, and therefore, cannot be verified. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, 
subacromial bursa); with ultrasound guidance, with permanent recording and reporting (20611 - 2 units) 
provided September 15, 2022.
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 the required services can be provided 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 complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, but this can be provided in a lower 
level of care. There is documentation that there is 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, but the services 
required can be provided at a lower level of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. 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 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 Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
requested use of Retacrit is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services (0242U) provided on June 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the out-of-network service was not pre-authorized. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the lab services by a contract provider. The file does not show that the plan 
provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for lab services (0242U) 
provided on June 23, 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 a fungal-infection polymerase chain reaction (PCR) panel 
provided on May 2, 2023. 
 
You asked the Plan to pay for a fungal-infection PCR panel. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the services at issue were 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 pay for a fungal-infection PCR panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the current standard of care for investigation of onychomycosis in a toenail is to 
perform a potassium hydroxide (KOH) test and/or fungal culture to the specimen. These lab tests are 
inexpensive, sensitive and specific. It is unclear as to why the enrollee's right hallux nail specimen required 
PCR testing when other less expensive and efficacious lab tests (KOH and fungal culture) are available. 
 
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 fungal-infection PCR panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a fungal-infection polymerase chain reaction (PCR) panel provided on May 2, 
2023.