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

 
We decided that the Plan has to pay for the 4Kscore test provided on June 14, 2023. 
 
You asked the Plan to pay for the 4Kscore test. You say that the provided 4Kscore test was medically 
necessary.  The Plan denied your request. The Plan says that the enrollee did not meet criteria for the provided 
4Kscore test. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the 4Kscore test. Our reviewer says that the 
enrollee met criteria for the provided 4Kscore test. Our physician reviewer found the enrollee is with prostate-
specific antigen (PSA) of 5.49 and no prior biopsies. Digital rectal exam without nodules. The enrollee meets 
all of the criteria for the LCD for this diagnostic test (4Kscore test). 
 
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 4Kscore test have been met. Therefore, we decided that the Plan has to pay 
for the 4Kscore test provided on June 14, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on February 
24, 2023. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that this should be covered by the 
hospital, because you had to be transported from one hospital to the other because of surgical complications. 
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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for an ambulance ride. This item/service falls within the 
ambulance services 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 copayment for an ambulance ride 
provided on February 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on September 1, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure 
provided.  Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on 
September 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) (93010) provided on July 13, 
2023. 
 
You asked the Plan to pay for the ECG. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says code 93312 and 93010 were billed on the same date of service. Code 
93010 has a Correct Coding Modifier Indicator (CCMI) of "1". This code was not billed with an appropriate 
modifier to bypass the edit. Therefore, code 93010 is not supported. 
 The Plan must follow Medicare rules. Medicare rules say that the National Correct Coding Initiative (NCCI) 
File Formats continue to include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column 
Two Correct Coding edit file. This indicator determines whether an NCCI PTP-associated modifier causes the 
code pair to bypass the edit. The CCMI will be either a "0," "1," or a "9." 
 
We looked at the file and Medicare rules. Code 93010 was billed without an appropriate modifier to bypass the 
NCCI edit. In this case, we have confirmed that code 93010 is a column II code to column I code 93312. Based 
on this information, we decided that Medicare rules for coverage of the ECG have not been met. Therefore, we 
decided that the Plan does not have to pay for the electrocardiogram (ECG) (93010) provided on July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a residence visit provided on August 3, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the residence visit. You say that the visit was medically necessary. The Plan 
denied your request. The Plan says that their original decision to deny payment was correct.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out-of-area urgent care, and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a residence visit provided on August 3, 2023, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 rendered on July 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 prior findings were upheld for CPT 29581. 
 
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 29581 is ""Application of multi-layer compression 
system; leg (below knee), including ankle and foot." 
 
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, modifier 59 is not 
supported, as a dressing was applied to the treated wound on right leg. Dressings are not reported separately from the procedure when both performed same anatomical area. 
 
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 29581 rendered on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services performed on August 2, 2023, through 
August 30, 2023. 
 
You asked the Plan to pay for the dialysis services. You say that the dialysis services should be paid as billed 
because all required value codes are listed on the claim. The Plan denied your request. The Plan says the 
dialysis services are denied due to an incomplete/missing value code on the claim.  
 
The Plan must follow Medicare rules. Medicare rules say that all ESRD claims with dates of service on or after 
July 1, 2010, must indicate the applicable Kt/V (a measure of dialysis adequacy) reading reported with Value 
Code D5.  
We looked at the file and Medicare rules. In this case, we confirmed that on the electronic claim sent to the 
Plan, Value Code D5 is not documented as required per Medicare rules. Based on this information, we decided 
that Medicare rules for coverage of the dialysis services have not been met. Therefore, we decided that the Plan 
does not have to pay for the dialysis services performed on August 2, 2023, through August 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on July 31, 
2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that you are on a fixed income 
and have a chronic condition. You cannot afford to pay these copayments. 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 $300 
copayment for inpatient hospital services.  
You have been asked to pay a $300 copayment for an acute inpatient stay. This item/service falls within the 
inpatient hospital services 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. You have been asked to pay a total of $300 for the inpatient hospital stay. You have not 
been charged for the day you were discharged. Therefore, we decided that the Plan does not have to waive the 
copayment for an acute inpatient stay provided on July 31, 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the services you need can be rendered at a lower level of 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 your 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. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory infusion pump, single or multiple channels, 
electric or battery operated, with administrative equipment, worn by patient (E0781) provided April 30, 2023.  
 
You asked the Plan to pay for the ambulatory infusion pump. You say that please see attached orders and 
progress notes. review claim again for payment. The Plan denied your request. The Plan says the clinical 
information does not support coverage of an infusion pump under Medicare rules. 
 
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 the ambulatory infusion pump. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not specify why drug needs to be administered as a 
continuous infusion and thus does not meet criteria for requested services coverage. 
 
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 ambulatory infusion pump have not been met. Therefore, we decided that 
the Plan does not have to pay for the ambulatory infusion pump, single or multiple channels, electric or battery 
operated, with administrative equipment, worn by patient (E0781) provided April 30, 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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the required services can be provided to the enrollee in 
an alternate setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's comorbid conditions do not require active management from a PM&R 
doctor thrice weekly and the enrollee is near their baseline in terms of oxygen requirements. The enrollee needs 
do not require the intensive, interdisciplinary care provided at an inpatient rehabilitation facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre CGM sensor kit. 
 
You asked the Plan to pre-approve a CGM sensor kit. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre CGM sensor kit.
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 you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is being considered for a renal biopsy in light of his worsening renal 
function. His acute inpatient hospitalization care is ongoing and discharge to an inpatient rehabilitation facility 
is premature.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 
03, 2023, to July 16, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were admitted due 
to a failed procedure. 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 $325 
copayment for in-network inpatient hospital care. 
 
You have been asked to pay a $325 copayment for the inpatient hospital stay. This item/service falls within the 
in-network inpatient hospital care 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. You have been asked to pay a total of $1,950 for the inpatient hospital stay 
($325 copayment x 6 days = $1,950). You have not been charged for the day you were discharged. Therefore, 
we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 
03, 2023, to July 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac-joint fusion procedure (27280). 
 
You asked the Plan to pre-approve sacroiliac-joint fusion. You say that a sacroiliac-joint fusion is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a sacroiliac-joint fusion 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 sacroiliac-joint fusion. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no sacroiliac joint instability, fracture or lesion evident in the medical record. Sacroiliac 
joint fusion for degenerative back pain is experimental. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac-joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac-joint fusion procedure (27280).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiography provided on August 02, 
2023. 
 
You asked the Plan to pay for the transthoracic echocardiography. You say that requesting reconsideration 
stating the enrollee visited this provider for evaluation of interstitial lung disease. 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 the transthoracic 
echocardiography provided on August 02, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for altered mental status observation provided by an out-of-network 
provider on September 21, 2023. 
 
You asked the Plan to pay for observation. You say that observation care does not require an authorization. The 
Plan denied your request. The Plan says that their original decision to deny payment was correct. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for altered mental 
status observation provided by an out-of-network provider on September 21, 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.