Persius/hicric huggingface dataset:
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 your records do not show that you have complex needs that require 
evaluation by a rehab doctor at least three times a week.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 17, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490 for date of service August 7, 2023. 
 
You asked the Plan to pay for code J3490. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the service at issue was not billed with the required modifier to allow separate 
payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 64420 
provided on the same date of service. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for code J3490 for date of 
service August 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9270 billed for June 2, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code A9270 has an OPPS status indicator of E1, 
meaning that the services are not covered when billed on an outpatient claim. This code is not separately 
payable. Therefore, we decided that the Plan does not have to pay for procedure code A9270 billed for June 2, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87563, 
87640, 87653, 87798, 87641, 87500, and 87491 for June 11, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that multiplex tests must be billed with only one testing 
code. 
 
We looked at the file and Medicare rules. The file shows that the panel was not billed with one single testing 
code. 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 the laboratory services billed with codes 
87481, 87563, 87640, 87653, 87798, 87641, 87500, and 87491 for June 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99285 billed on March 16, 2023. 
 
You asked the Plan to pay for 99285. You say that 99285 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99285 is denied because it is not supported in the 
documentation. 
 
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 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 99285. Our reviewer says that 99285 is not 
supported in the documentation. Our reviewer found documentation supports an appropriate exam, but not an 
appropriate history or medical decision making of high level, as required for billing 99285. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99285 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services described by code 99285 billed on March 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee has a diagnosis of severe short term 
memory impairment not consistent with Alzheimers disease. 
 
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 Leqembi. Our reviewer says that this 
drug is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of severe short term memory impairment not consistent with Alzheimers disease. Although the 
enrollee may have Alzheimer's disease, the record does not document the presence of mild cognitive impairment or mild dementia stage of disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75630. We decided that the Plan does not have to pay for 99153.  
 
You asked the Plan to pay for procedure codes 75630 and 99153 rendered on May 19, 2023. You say that this 
should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 75630.  
 
he Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. The definition of CPT 75630 is "Aortography, abdominal 
plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and 
interpretation." 
 
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 for CPT 75630. Our reviewer says that on May 19, 
2023, the enrollee had a coronary stent procedure. As part of the procedure abdominal aortagram was done - 
CPT 75630. The plan disputes this charge. A review of the records showed catheter placement into the 
abdominal aorta and description of the iliac and femoral arteries bilaterally. This description qualifies for the 
charge of CPT 75630. 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for 75630.  
 
We also decided that the Plan does not have to pay for 99153. 
 
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. Based on this information, we decided 
that Medicare rules for coverage of the item/service at issue have not been met. Therefore, we decided that the 
Plan does not have to pay for 99153. 
 
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 an over-the-counter (OTC) COVID-19 test provided on June 
26, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. The Plan denied your request. The Plan says OTC 
COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for OTC items, including 
self-administered COVID-19 tests. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the OTC COVID-19 test have not been met. Therefore, we decided that the Plan does not have to 
pay for an over-the-counter (OTC) COVID-19 test provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 1, 2023, and billed with 
codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-59, 81306-59, 81328-
59,81335-59 and 81479-59. 
 
You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 1, 2023, and billed with codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-59, 81306-59, 
81328-59,81335-59 and 81479-59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 13, 2023, billed with 
codes 81238, 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical records. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 13, 2023, billed with codes 81238, 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81335 and 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Spine ZIP interspinous fixation system. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of this system in the setting of low back pain 
secondary to lateral recess and foraminal stenosis have not been demonstrated in the peer-reviewed literature. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for vertebrogenic low back pain. She presented with pain in the 
sacral/coccyx area with tenderness to palpation. The exam reveals tenderness to palpation of the midline 
superior gluteal cleft. The strength is intact bilateral lower extremities. However, there is limited published, large-scale, long-term peer-reviewed literature that shows this requested interspinous device to be an effective 
and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request has 
beneficial outcomes compared with conventional treatment. No compelling rationale is presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested Aurora Spine ZIP interspinous fixation system 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Aurora Spine ZIP interspinous fixation system.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99203 rendered on June 8, 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 that 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 99203 is "Office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and low level of medical decision making. When 
using time for code selection, 30-44 minutes of total time is spent on the date of the encounter." 
 
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 supported by the medical records. Our reviewer found that the enrollee was referred to a 
urologist for evaluation of genital prolapse and a poorly managed pessary. An appropriate history and physical 
were documented. The medical decision making was of at least low complexity. The time spent caring for the 
enrollee is not noted, so time was not used for code selection. The billing of CPT 99203 is 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 the services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99203 rendered on June 8, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered on February 21, 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 documentation does not support the billed code. 
 
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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 
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 the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level, or that 75 minutes 
were spent. 
 
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 evaluation and management services (procedure code 99223) rendered on February 21, 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 enrollee's condition requires interdisciplinary 
therapy care to identify and treat any problems that may arise during their period of recovery. The Plan denied 
your request. The Plan says the enrollee's medical status is stable, and does not require an interdisciplinary 
approach to rehabilitative care.  
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patients 
medical problems are stable and there are no complex nursing or rehabilitation needs. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36556 and 76937 for date of service May 8, 
2023. 
 
You asked the Plan to pay for procedure codes 36556 and 76937. 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 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. 
 
The CPT Code Manual definition of code 76937 is ultrasound guidance for vascular access requiring 
ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in 
addition to code for primary procedure). 
 
We find that CPT codes 36556 and 76937 are not supported in the medical record. Specifically, the medical 
records submitted indicate that central line was placed via jugular catheter entry site. However, the records did 
not include documentation of the final position of the tip of the central venous device. This means the validity 
of code 36556 cannot be verified. The records submitted did not include documentation of vessel patency. This 
means the validity of code 76937 cannot be verified. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 36556 and 76937 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 36556 and 76937 for date of service May 8, 2023.