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

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 You asked the Plan to pre-approve an ESI. You say that the enrollee needs this injection. The Plan denied your 
request. The Plan says the documentation does not show the enrollee met the requirement for having tried and 
failed a 4-week course of noninvasive conservative care. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain criteria 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 an ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found the documentation does not show that 
the enrollee has met the requirement of having tried and failed a 4-week course of non-invasive conservative 
care. Therefore, the reviewer found that requested injection is not medically 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 an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service July 5, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service July 5, 2022, billed with 
code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99140 and 99100 billed for date of service 
November 17, 2022. 
 
You asked the Plan to pay for procedure codes 99140 and 99100. You say that you disagree with the denial. 
The Plan denied your request. The Plan says procedure codes 99140 and 99100 are considered bundled and not 
separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99140 and 99100 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99140 and 99100 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99140 and 99100 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99140 and 99100 billed for date of service 
November 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the request for admission to an 
IRF does not meet medical necessity guidelines. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) 
provided on September 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that molecular testing was requested directly from 
the treatment physician who makes the professional determination of diagnosis and medical necessity to 
successfully treat the enrollee. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 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 the targeted genomic sequence analysis panel 
(81455) provided on September 13, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you need a home ventilator because you 
have COPD and other devices are not appropriate. The Plan denied your request. The Plan says your needs can 
be met with a bilevel positive airway pressure (BiPAP) device with average volume-assured pressure support 
(AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found you were recently hospitalized 
with diarrhea and shortness of breath. A diagnosis of COPD and emphysema is listed. However, recent 
pulmonary function tests are most consistent with severe restrictive lung disease with an FEV1 of 46% of 
predicted and a normal FEV1/FVC ratio, and prior clinical notes indicate interstitial lung disease.  There are 
also diagnoses of heart failure, pulmonary hypertension, and chronic kidney disease. There is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. There is no arterial blood gas done while stable to 
document chronic CO2 retention.  If that is present, the patient may benefit from BiPAP with AVAPS during 
sleep as an outpatient.  Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services and mileage provided on January 17, 2023. 
 
You asked the Plan to pay for the ambulance services and mileage. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Review of the file shows that the Plan states that this 
service is a repeat or duplicate charge. The documentation shows that two ambulance trips were provided on 
the same date of service billed with different codes. Based on this information, we decided that Medicare rules 
for coverage of the ambulance services and mileage have been met. Therefore, we decided that the Plan has to 
pay for the ambulance services and mileage provided on January 17, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12011 billed for date of service October 8, 
2022. 
 You asked the Plan to pay for procedure code 12011. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 12011 is bundled into payment for code 12001. 
 
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 12011 
is a column II code to column I code 12001. 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 procedure code 12011 billed for date of service October 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy, flexible; diagnostic (code 45378) provided on 
September 24, 2022. 
 You asked the Plan to pay for the colonoscopy, flexible; diagnostic. You say that the requested colonoscopy 
was medically necessary. The Plan denied your request. The Plan says the requested diagnostic colonoscopy 
does not meet the Medical LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 colonoscopy, flexible; diagnostic. Our 
reviewer says that the requested colonoscopy is not considered medically necessary in this case. Our physician 
reviewer found that based on the medical records provided there is no documentation that the diagnostic 
colonoscopy provided on September 24, 2022, at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. The provided records in this case document that the indication for 
the procedure was screening for colon cancer. The records do not document the colonoscopy was performed for 
any of the indications cited in the LCD - Diagnostic Colonoscopy (L38812).  
 
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 colonoscopy, flexible; diagnostic have not been met. Therefore, we decided 
that the Plan does not have to pay for a colonoscopy, flexible; diagnostic (code 45378) provided on 
September 24, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the injection services identified with codes 96372, J2353, and 96365 
provided on November 3, 2022. 
 
You asked the Plan to pay for the injection services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the services do not meet the coverage requirement in the applicable 
Local Coverage Determination (LCD) or National Coverage Determination (NCD). 
 
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 states that the services do not meet the coverage requirement in the 
applicable LCD or NCD. The Plan did not give explanation on why these services do not meet coverage 
criteria. No LCD or NCD were provided to support this denial. The Plan did not substantiate their denial. 
Therefore, we decided that the Plan has to pay for the injection services identified with codes 96372, J2353, 
and 96365 provided on November 3, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig (A9282). 
 
You asked the Plan to pre-approve a wig. You say that you disagree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says your request for a wig is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
 
 
 In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).
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 the enrollee meets the guidelines. The 
Plan denied your request. The Plan says the LTACH services requested to not meet the requirements for 
approval, and the services needed can be provided at a different level of care. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care.  
 The Plan has approved ongoing care in the current acute care setting. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81295 and 81298 billed for date of service 
November 7, 2021. 
 
You asked the Plan to pay for procedure codes 81295 and 81298. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says payment for codes 81295 and 81298 is 
bundled into payment for code 81432. 
 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 codes 
81295 and 81298 are column II codes to column I code 81432. Both code pairs have a modifier indicator of 0. 
The column II codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 81295 and 81298 billed 
for date of service November 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for optometry services (V2020, V2200, and V2200) provide on 
July 20, 2022. 
 
You asked the Plan to pay for the optometry services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 V2020, V2200, and V2200 is not supported in the medical record. Specifically, only a 
single page of records was provided. Insufficient records were provided to show that the refractions or sphere, 
bifocal, plano to plus or minus 4.00d,per lens, were performed. Based on this information, we decided that 
Medicare rules for coverage of the optometry services have not been met. Therefore, we decided that the Plan 
does not have to pay for optometry services (V2020, V2200, and V2200) provide on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve injection. You say that the enrollee needs this injection. The Plan denied 
your request. The Plan says the requested 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 injection. Our reviewer says that the 
requested SI joint injection is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation on physical examination of tenderness to the SI joint and no mention 
of SI provocative testing being completed with positive findings. Therefore, the reviewer found that the 
requested SI joint injection 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 injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography provided on November 2, 2022. 
 
You asked the Plan to pay for the echocardiography. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the echocardiography provided on November 2, 2022.