Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat injection of Triamcinolone acetonide (Zilretta). 
 
You asked the Plan to pre-approve Zilretta. You say that Zilretta has shown to decrease the enrollee's overall 
pain. The Plan denied your request. The Plan says that the safety of a repeat injection has not been 
demonstrated.  
 
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 Zilretta. Our physician reviewer found 
that the enrollee has a history of left knee pain due to osteoarthritis of the left knee. He has been treated with 
medication and a previous Zilretta injection. Zilretta is indicated as an intra-articular injection for the 
management of osteoarthritis pain of the knee. The review has determined that the requested use of Zilretta is 
FDA-approved for the enrollees diagnosis. Its use is supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. The requested use is not listed as not 
indicated, not supported or not recommended in any of the compendia. The documentation does support that 
the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve a 
repeat injection of Triamcinolone acetonide (Zilretta).  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to a LTACH. 
 
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 somewhat unstable and requires additional acute care 
hospital services that can safely be provided at the current facility until more stable and appropriate for transfer 
to a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 24, 2022, to 
September 22, 2022. 
 You asked the Plan to pay for the home health services. You say that these services were medically necessary 
and provided in good faith. 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 April 26, 2022. The NOA was not received by the Plan until January 16, 
2023. 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 August 24, 2022, to September 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman device (22612, 22840, 22899).  
 
You asked the Plan to pre-approve the Minuteman device. You say that the enrollee has failed or not sustained 
long-term benefits from conservative treatment within the past 12 months. The Plan denied your request. The 
Plan says this device is not approved for use in a stand-alone procedure. 
 
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 Minuteman device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that according to the Food and Drug Administration (FDA), The HA Minuteman G3-
R MIS Fusion Plate is a posterior, non-pedicle supplemental fixation device, intended for use at a single level 
in the non-cervical spine (T1-S1). The HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft material and is not intended for stand-alone use. In addition, fusion indications within guidelines/literature 
for (existing or potential intraoperative) instability have not been documented and/or met in this case. In 
addition, there are multiple alternate pain generators plausibly significantly contributing to the clinical 
condition that have not been fully documented as having been excluded and/or ruled out. No compelling 
rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested Minuteman device at L4-5 is not medically reasonable or 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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Minuteman device (22612, 22840, 22899).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a GeneSight Psychotropic test (81479) billed for date of 
service November 23, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says this molecular pathology testing is not a Medicare-covered benefit. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the DEXTM Diagnostics Exchange does not show that the 
test at issue is covered. Based on this information, we decided that Medicare rules for coverage of genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for a GeneSight 
Psychotropic test (81479) billed for date of service November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on March 01, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on March 01, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurotomy with imaging guidance (64636, 64635). 
 
You asked the Plan to pre-approve neurotomy with imaging guidance. You say that under Medicare guidelines, 
your request is not medically necessary because your records show you do not have 
two diagnostic medial branch blocks yielding 80% or better improvement in pain.  The Plan denied your 
request. The Plan says the enrollee wants a non-surgical approach to treatment and to lower pain level.  
 
The Plan follows Medicare rules. Medicare rules say that neurotomy is covered when medically 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 pre-approve neurotomy with imaging guidance . Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that radiofrequency 
ablation of the lateral sacral branches is considered experimental due to the wide variation in efficacy in the 
literature. Therefore, the request is deemed not medically reasonable or 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 neurotomy with imaging guidance have not been met. Therefore, we decided 
that the Plan does not have to pre-approve neurotomy with imaging guidance (64636, 64635).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 01926 and 36620. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 93312.  
 
You asked the Plan to pay for the medical services provided on March 30, 2023, billed with codes 01926, 
36620, and 93312. You say that you believe that the claim should be paid as billed. The Plan says that code 
93312 is included in payment with code 01926. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 01926 and 36620.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 01926 and 36620.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
93312. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 93312 is a column II code to column I code 01926. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services described 
by procedure code(s) 93312. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93010) provided on October 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that cardiovascular stress tests include insertion of 
needle and/or catheter, infusion/injection (pharmacologic stress tests) and ECG strips (e.g., CPT codes 36000, 
36410, 96360-96379, 93000-93010, 93040-93042). These services shall not be reported separately.  
 
We looked at the file and Medicare rules. Per Medicare rules, the ECG strips are not separately payable. 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 (93010) provided on October 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99281) provided on 
February 28, 2023. 
 
You asked the Plan to pay for an emergency department visit. You say that you disagree with the denial and 
have submitted medical records for reconsideration of payment. The Plan denied your request. The Plan says 
the diagnosis code is not eligible for payment on this claim. 
 
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 code 99281 is not supported in the medical record. Specifically, the diagnosis code used is 
not eligible for payment because the code indicates that the procedure code was not carried out. The records 
show that the enrollee left prior to being seen by a health care provider. Based on this information, we decided 
that Medicare rules for coverage of an emergency department visit have not been met. Therefore, we decided 
that the Plan does not have to pay for an emergency department visit (99281) provided on February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing, 22 or more drug classes (G0483) 
provided March 15, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the lab order has what drug classes were tested 
which validates the billed service. See the ordered tests and reprocess the claim for payment.  The Plan denied 
your request. The Plan says the records do not support service 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any 
type, single or tandem and excluding immunoassays and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix 
effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-
matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative 
or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including 
metabolite(s) if performed . 
 
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 drug testing. Our reviewer says that the records do not 
support procedure code G0483. Our reviewer found the record does not contain evidence that 22 or more drug 
classes were tested. According to the record, there is a more specific code for the number of classes tested.  
 
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive drug testing, 22 or more drug classes (G0483) provided March 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service January 19, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99285. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented with weakness and 
dizziness to the Emergency room and not having pain medications. The documentation supports an appropriate 
exam, but not an appropriate history or medical decision making of high level. Therefore, code 99285 is not 
supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service January 19, 2023.
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 the services are medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for January 16, 2023. 
 
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 99284 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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function.  
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 these services. Our reviewer says that procedure code 99284 
is not supported. Our reviewer found the enrollee presented to the emergency department (ED) with complaints 
of right wrist pain present for four months. There was no injury or trauma. The history of present illness is 
problem-focused and without detail. The examination is expanded with focus on the problem. The presenting 
problem is not of high severity. The billing of 99284 is not supported by the submitted records. 
 
We looked at this coder's review, the file, and Medicare rules. 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 99284 billed for January 16, 2023.