Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vulvectomy simple; partial (56620). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the enrollee has had persistent lesions 
for at least 4 months duration. You say that a biopsy indicated benign condyloma acuminatum with no high-
grade dysplasia or malignancy. You also say that this service is necessary to further confirm no abnormal tissue 
exists. The Plan denied your request. The Plan says this 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 the outpatient procedure. Our reviewer 
says that the requested partial vulvectomy is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the notes describe the enrollee as not sexually active, without significant 
symptoms directly related to the lesions. The reviewer also found that there is no supportive literature to justify this procedure for benign lesions. Therefore, the reviewer found that the request for partial vulvectomy 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 the outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vulvectomy simple; partial (56620).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Intracept procedure provided on March 23, 2022. 
 
You asked the Plan to pay for the Intracept procedure. You say that you were told by the physician and the 
surgery center that this procedure would be covered. The Plan denied your request. The Plan says the Intracept 
procedure was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes without facet 
degenerative joint disease or stenosis. The cause of pain is not clear. 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the Intracept procedure provided on March 23, 2022.
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's medical needs are not 
being met at the skilled nursing facility. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for a LTACH admission. 
 
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 physician 
reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this 
case. Our reviewer found that the record indicates that the enrollee has acute medical issues and still requires 
acute care services. The enrollee continues to receive acute care services, and these have not been denied. 
The medical record does not indicate that the enrollee requires services that he is not currently receiving but 
that would be available at the LTACH 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says that the enrollee does not meet the Medicare criteria for LTACH services. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the documentation provided, the enrollee meets LTACH criteria due to their complex 
wound care condition requiring LTACH care and need for long-term IV antimicrobial therapy with daily 
monitoring and adjustment of care. At this time the enrollee does not require hospitalization in a standard, short 
term acute care hospital and is stable to be moved to a long term, acute care hospital. Their needs cannot be met 
at a lower level of care such as SNF or home health. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
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 pre-approve RFA of the genicular nerve. 
 
You asked the Plan to pre-approve the RFA. You say that you are in a lot of pain, and nothing helps besides 
these injections. The Plan denied your request. The Plan says the request 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 the RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 
 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve RFA of the genicular nerve.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine identified by code J3490 provided on July 10, 
2023. 
 
You asked the Plan to pay for bupivacaine. You say that this code should be paid. The Plan denied your 
request. The Plan says this code is bundled into the payment for the surgical procedure and is not separately 
paid. 
 
The Plan must follow Medicare rules. Medicare rules say that services integral to accomplishing a procedure 
are considered bundled into the procedure and are therefore it is inappropriate to separately report the service.  
 
We looked at the file and Medicare rules. A local anesthetic agent such as bupivacaine is integral to 
accomplishing the primary surgical procedure and therefore should not be separately reported or paid. Based on 
this information, we decided that Medicare rules for coverage of bupivacaine have not been met. Therefore, we 
decided that the Plan does not have to pay for bupivacaine identified by code J3490 provided on July 10, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis (J2778). 
 You asked the Plan to pre-approve Lucentis. You say that the requested Lucentis (J2778) is medically necessity 
for the enrollee's treatment for diabetic macular edema and diabetic retinopathy. The Plan denied your request. 
The Plan says the Plan's step therapy criteria has not been met for the requested drug. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Lucentis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has diabetic macular edema with diabetic 
retinopathy. The requested medication is a new start. The provided records do not indicate that the enrollee has 
tried and failed the Plan's preferred step one alternative. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative. The elements 
of the coverage criteria are not satisfied, and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis (J2778).
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 LTACH is medically necessary.  
The Plan denied your request. The Plan says  the LTACH services are not medically necessary, and the 
enrollee's needs are being met in the current location. 
 
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 was admitted to the acute care hospital with congestive heart failure exacerbation, 
myocardial infarction, colitis, and obstructive uropathy complicated by hypotension and requiring 
vasopressors, diuresis, antibiotics, and heparin drip. The enrollee appears to still be somewhat unstable and not improving significantly and requires additional acute care services that can safely be provided at the current 
facility until more stable and appropriate for a transfer. 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on March 9, 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 CPT 99284 is not eligible for payment. 
 
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 a medically appropriate history and/or examination and moderate 
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 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 medical decision making of 
moderate complexity requires 2 out of 3 of multiple diagnoses or management options, a moderate amount and 
complexity of data reviewed and moderate risk of complication. The provided records in this case do not 
document 2 out of 3 of multiple diagnoses or management options, a moderate amount and complexity of data 
reviewed and moderate risk of complication. 
 
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 emergency room services (procedure code 99284) rendered on March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor supplies (A4239) provided on March 
20, 2023. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that supplies were 
ordered on March 6, 2023, with code K0553. 
 
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 argues that supplies were ordered on March 6, 2023, with code K0553. 
However, the Plan has not provided documentation in the form of a claim or Explanation of Benefits showing 
that code K0553 was billed within the previous 30 days. Without supporting documentation, the Plan's denial 
cannot be substantiated. Therefore, we decided that the Plan has to pay for the continuous glucose monitor 
supplies (A4239) provided on March 20, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on January 6, 2023, billed with codes 
87652 and 87900. 
 
You asked the Plan to pay for the lab testing as billed. You say that this testing was medically necessary and 
should be paid. The Plan denied your request. The Plan says the codes at issue 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 87652 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group A, quantification. The definition of code 87900 is infectious agent drug 
susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
 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 lab testing as billed. Our reviewer says that the codes at 
issue are not supported by the records. Our reviewer found code 87652 is not supported as this code includes 
quantification which was not done as no pathogen of this type were detected. Code 87900 is also not supported 
as this service would include the lab analyst measuring the patient's susceptibility or resistance to drugs aimed 
at a virus. The clinician can use the information to help in deciding which drugs to prescribe. This lab report 
does not document these services. 
 
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 lab testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab testing provided on January 6, 2023, billed with codes 87652 and 87900.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800), 
 
You asked the Plan to pre-approve a power scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says there is no documentation of a face to face evaluation by the ordering 
provider regarding mobility limitations that impair the ability to complete activities of daily living in the home 
or that place you at increased risk of falls or whether your mobility limitations are not able to be ameliorated with a cane, walker or manual wheelchair, nor is there a formal home assessment provided by the medical 
equipment supplier. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, the patient is not capable of safely operating the requested PMD, there is 
not adequate room in their home for maneuvering, or there is no face-to-face encounter with physician. 
 
The file shows that there is no documentation of a face to face evaluation by the ordering provider regarding 
mobility limitations that impair the ability to complete activities of daily living in the home or that place you at 
increased risk of falls or whether your mobility limitations are not able to be ameliorated with a cane, walker or 
manual wheelchair, nor is there a formal home assessment provided by the medical equipment supplier. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800),
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy with lesion removal (45385) provided on 
March 31, 2023. 
 You asked the Plan to pay for the colonoscopy. You say that medical records submitted support code 45385-
XS and should be paid. The Plan denied your request. The Plan says the documents received do not support 
that the procedure or service was distinct or independent from other services performed; therefore, code 45385-
XS 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, we have confirmed that code 45385 is a column II code to column I code 45388; however, 45385 
was billed with a modifier.  
 
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 colonoscopy. Our reviewer says that the records states 
that the snare polypectomy was performed at the same site as the ablation procedure. In this case, only the more 
extensive procedure is reported, which is the ablation. The record does not support that these procedures were 
performed at separate sites, therefore, code 45385-XS 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 the colonoscopy have not been met. Therefore, we decided that the Plan does 
not have to pay for the colonoscopy with lesion removal (45385) provided on March 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490 for date of service May 1, 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 64624 
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 May 1, 2023.