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

 
We decided that the Plan does not have to pay for the unclassified drugs identified with code J3490 for date of 
service October 10, 2022. 
 
You asked the Plan to pay for the unclassified drugs. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are 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 CPT code. 
 
In this case, the CPT Code Manual definition of code J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service is considered 
part of the global surgery period for procedure code 27096, which was provided on the same date of service. 
An appropriate modifier was not billed. The claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the unclassified drugs have not been met. Therefore, we decided 
that the Plan does not have to pay for the unclassified drugs identified with code J3490 for date of service 
October 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac imaging is only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that there is no documentation that the ECG shows an uninterpretable pattern or that the 
enrollee is unable to exercise. There is no evidence provided that would support the need for radionuclide stress 
testing at this time. There is insufficient documentation to support the medical necessity for the requested 
cardiac stress testing in this enrollees clinical management. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve myocardial perfusion imaging.
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 not strong enough to care for yourself, and 
the skilled nursing facility was not a good experience. You say you just need to regain enough strength to walk 
up and down the stairs to get to the bathroom. The Plan denied your request. The Plan says the IRF services 
you are requesting do not meet the requirements for approval. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 13, 2022, to July 
16, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support code K80.43 as the principal diagnosis and code K85.10 as the secondary diagnosis 
with a DRG of 417. The Plan denied your request. The Plan says they re-sequenced code K80.43 as a 
secondary diagnosis code and re-sequenced code K85.10 as the principal diagnosis code, resulting in the 
change of the DRG from 417 to 418. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with K80.43 - calculus of bile duct with acute 
cholecystitis with obstruction and K85.10 - biliary acute pancreatitis without necrosis or infection. 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 inpatient hospital services at the DRG originally 
billed. Our physician reviewer found the enrollee was admitted with evidence of biliary obstruction and 
pancreatitis. Treatment for the two conditions is similar but the record consistently notes uncomplicated acute 
pancreatitis. Cholestais is responsible for the enzyme elevation. The enrollee was treated and monitored for 
acute pancreatitis. The Plan has coded correctly.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 13, 2022, to July 16, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
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 for the enrollee 
to receive the therapy services needed. The Plan denied your request. The Plan says ongoing skilled care can be 
provided in an alternative 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 is medically stable. While the enrollee may benefit from physical and 
occupational therapy, their rehab needs can be provided in a lower intensity and alternate setting such a skilled 
nursing 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: 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 an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute 
IRF setting have 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 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 and/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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan Hycela. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
membranous glomerular nephritis. The Food and Drug Administration (FDA) has not stated that the requested 
drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the 
coverage criteria are not satisfied and the services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rituxan Hycela.
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 needs can be met at an alternate 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 that you are medically stable. While you  may benefit from physical and occupational 
therapy, your rehab needs can be provided in a lower intensity and alternate setting such a skilled nursing 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code 88305. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 88305 is not supported as billed in the case record. Specifically, the code at issue was billed with an outpatient place of service (POS) code. The Plan has documented that the enrollee was classed as 
an inpatient on the date of service at issue. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 88305 billed for date of service November 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroxine measurement (84439) and stimulating thyroid 
hormone (TSH) testing (84443) provided December 27, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please see the attached medical record 
which clearly supports the medical necessity of the denied claim. The Plan denied your request. The Plan says 
these procedure codes are not payable with the diagnosis codes of C80.1 and C80.0. 
 
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 88439 is thyroxine measurement and 84443 is 
stimulating thyroid hormone (TSH) testing. 
 
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 laboratory services. Our reviewer says that the Medicare 
criteria has not been met. Our reviewer found the documentation submitted was reviewed, and CPT codes 
88439 and 84443 does not meet criteria. The provider reported the procedure codes 88149 and 84443 with ICD 
10 diagnosis codes C80.1: malignant (primary) neoplasm, unspecified, and C80.0: disseminated malignant 
neoplasm, unspecified. Thyroid function tests are used to define hyper function, euthyroidism, or hypofunction 
of thyroid disease, and in this case an unspecified malignant diagnosis code does not support the service billed. 
Thyroid function testing may be medically necessary in patients with disease or neoplasm of the thyroid and 
other endocrine glands. Thyroid function testing may also be medically necessary in patients with metabolic 
disorders; malnutrition; hyperlipidemia; certain types of anemia; psychosis and non-psychotic personality 
disorders; unexplained depression; ophthalmologic disorders; various cardiac arrhythmias; disorders of 
menstruation; skin conditions; myalgias; and a wide array of signs and symptoms, including alterations in 
consciousness; malaise; hypothermia; symptoms of the nervous and musculoskeletal system; skin and 
integumentary system; nutrition and metabolism; cardiovascular; and gastrointestinal system. In this case, there 
is insufficient diagnosis to support procedure billed. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the thyroxine measurement (84439) and stimulating thyroid hormone (TSH) testing 
(84443) provided December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown and core buildup for tooth number 20. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that the criteria for coverage has not been met. 
 
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 failed to support their denial by providing the medical records used to 
deny coverage. Therefore, we decided that the Plan has to pre-approve a crown and core buildup for tooth 
number 20.  
 
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 procedure codes 99222 and 99223 billed for dates of service 
from December 8, 2022, to December 12, 2022. 
 
You asked the Plan to pay for procedure codes 99222 and 99223. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 99222 is: Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
The definition of code 99223 is: Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical 
decision making of high complexity. Counseling and/or coordination of care with other physicians, other 
qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 
70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT codes 99222 and 99223 are not supported. Specifically, the case record indicates that you 
have billed initial hospital care for date of service December 7, 2022. Care provided on the following dates of 
service should be reported with codes denoting subsequent rather than initial care. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 99222 and 99223 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 99222 and 99223 billed for dates 
of service from December 8, 2022, to December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88120 billed for date of service October 10, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the reports support the services billed. The Plan 
denied your request. The Plan says the service is not a Medicare benefit for the billed diagnosis. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that cytopathology, in situ hybridization (e.g., FISH) testing was provided due to hematuria. 
FISH testing is not covered for screening of those with hematuria. Therefore, we decided that the Plan does not 
have to pay for procedure code 88120 billed for date of service October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endocrinology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says services are 
available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
endocrinology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare 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 pre-approve an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that the epidural steroid injection on February 29, 2023, provided 80% pain 
relief for only 2.5 weeks. This does not meet the Medicare LCD criteria of 50% pain improvement for three 
months. Therefore, the request is not medically reasonable and 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.