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

 
We decided that the Plan does not have to pre-approve the Sclerotherapy (36471). 
 
You asked the Plan to pre-approve the Sclerotherapy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux (the condition that leads to most cases of varicose veins) is not present 
or already successfully eliminated, the veins are less than 4 millimeter (mm) in diameter and if the patient 
remains symptomatic after a six-week trial of conservative therapy.  
 
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 Sclerotherapy. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the patient has not yet undergone 
saphenous vein reflux treatment 
 
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 Sclerotherapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Sclerotherapy (36471).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service 
November 17, 2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that you have provided medical records to 
support the necessity of this service. The Plan denied your request. The Plan says payment for code 70450-26 
is bundled into payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service 
November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on October 31, 2022. 
 
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 performed by the same and/or different provider for the same date of 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare will only pay for one presumptive test result 
per patient per date of service regardless of the number of billing providers. 
 
We looked at the file and Medicare rules. The file shows that the Plan previously paid for drug testing for this 
enrollee for the same date of service. 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 drug testing 
rendered on October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84480 and 84436 billed for date of service 
September 12, 2022.   
You asked the Plan to pay for procedure code 84480 and 84436. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says payment for codes 84480 and 84436 
is bundled into payment for codes 84481 and 84439. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
84480 and 84436 are column II codes to column I codes 84481 and 84439 with a modifier indicator of 0. The 
column II codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 84480 and 84436 billed 
for date of service September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85060, 88271, 88275 and 88342 billed for 
date of service December 6, 2022. 
 
You asked the Plan to pay for procedure codes 85060, 88271, 88275 and 88342. You say that you have billed 
the services at issue correctly. The Plan denied your request. The Plan says payment for codes 88271 and 
88275 is bundled into payment for code 88368. Payment for code 88342 is bundled into payment for code 
88189. No payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 88271 and 88275 are column II codes to column I code 88368, and 
that code 88342 is a column II code to column I code 88189. These claim lines have not been billed with an 
appropriate modifier to bypass the edits. Additionally, no payment is recognized for code 85060 furnished to 
hospital outpatients or non-hospital patients. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 85060, 88271, 88275 
and 88342 billed for date of service December 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries (93925) and 
limited bilateral non-invasive physiologic studies of upper or lower extremity arteries (93922). 
 
You asked the Plan to pre-approve a duplex scan of lower extremity arteries and limited bilateral non-invasive 
physiologic studies of upper or lower extremity arteries. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is not enough documentation to support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
   
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a duplex scan of lower extremity 
arteries and limited bilateral noninvasive physiologic studies of upper or lower extremity arteries have been 
met. There are no medical records within the casefile. Without the requested clinical information, we are 
unable to determine if the requested services are medically necessary. The Plan made multiple attempts to 
request additional medical records. Therefore, we decided that the Plan does not have to pre-approve a duplex 
scan of lower extremity arteries (93925) and limited bilateral non-invasive physiologic studies of upper or 
lower extremity arteries (93922).
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 an LTACH level of care is the best 
option for a safe discharge due to the need for frequent nursing care, daily physician management by multiple 
specialties, wound vacuum management, daily laboratory tests, physical therapy, and occupational therapy. The 
Plan denied your request. The Plan says admission to the LTACH is not medically necessary.  
 
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 all medically necessary care is being provided in the current acute care setting. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-pneumatic compression controller (K1024) and 
non-pneumatic sequential compression garment (K1033).   
 
You asked the Plan to pre-approve the non-pneumatic compression controller and non-pneumatic sequential 
compression garment. You say that the items are medically necessary. The Plan denied your request. The Plan 
says the items are 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 non-pneumatic compression 
controller and non-pneumatic sequential compression garment. Our reviewer says that the requested items are 
not considered medically reasonable and necessary in this case. Our physician reviewer found there is no 
objective evidence (i.e., measurements, description) of the lymphedemas response to conservative treatment.   
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 non-pneumatic compression controller and non-pneumatic sequential 
compression garment have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
non-pneumatic compression controller (K1024) and non-pneumatic sequential compression garment (K1033).
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 this is the appropriate level of care for the enrollee 
that needs physical and occupational therapy. The Plan denied your request. The Plan says the enrollee's 
records do not show the need for an intensive team for care. Services needed may be provided safely in 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on January 23, 2023. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that due to the patients condition at the time of transport, any other means of transport would 
be unsafe. The Plan denied your request. The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance service, basic life support, 
non-emergency transport and ground mileage. Our reviewer says that the ambulance services were not 
medically necessary. Our physician reviewer found the transportation via ambulance to and from the hospital to 
the nursing home was not medically necessary.  The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance 
in order to effectuate a safe transport.  Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport and ground mileage provided on January 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.   
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service November 1, 2022. 
 
You asked the Plan to pay for code 99285. You say that the level of care billed is supported by the medical 
records. The Plan denied your request. The Plan says code 99285 is not supported by the medical record. The 
records do not support medical decision making of high complexity. 
 
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 these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the provided medical records document a chief 
complaint, an extended history of present illness, a review of all additional body systems but do not document a 
complete past, family and social history. The provided medical records document a general multisystem 
examination. The provided medical records do not document 2 out of 3 of an extensive number of diagnoses or 
management options, an extensive amount and complexity of data reviewed and high 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 code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service November 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to the IRF is necessary because you need 
to recover from injuries sustained in a bicycle accident and your recovery is challenged by multiple 
comorbidities. You say you feel you would benefit from a more intensive rehabilitation to regain your 
independence. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
admission to an IRF.  
 
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 the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on January 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes M62.81 and 
M33.20. Diagnosis code M62.81 has an Excludes1 note and cannot be billed with diagnosis code M33.20. 
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 the therapy services provided on January 12, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the thyroid stimulating hormone testing (84443) provided November 
10, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing this charge because the 
tests performed were requested by your doctor. The Plan denied your request. The Plan says that procedure 
84443 does not meet the associated diagnosis code relationship. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory service by a contract provider. The file does not show that the Plan 
provided notice that the laboratory service would not be covered. Under Medicare rules, this means the 
laboratory service is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
thyroid stimulating hormone testing (84443) provided November 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a continuation of care with an out-of-network (OON) 
pain management provider. 
 
You asked the Plan to pre-approve  a continuation of care with an OON pain management provider.. You say 
that if you were to have to start with a new pain specialist you would have to start from square-one. You say 
that you have total trust in the OON provider you have been seeing, and that this provider knows all of your 
ailments. You say that the OON provider knows the ins and outs of all of your medical issues and pain.  The 
Plan denied your request. The Plan says they have equally qualified pain management providers within the 
network who can treat you. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a continuation of care with an OON 
pain management provider. Our reviewer says that the criteria for coverage of OON care have not been met.  
Our physician reviewer found the provided medical records do not document any active treatment and/or 
medical management of your condition that makes it medically necessary for you to continue care with the 
OON provider as requested. The provided medical records do not document anything unique about your 
condition that would make it medically necessary for you to continue care with the OON provider. The plan 
has pain management providers who appear to have the qualifications and expertise necessary to meet the 
current medical Standards of Care required for treatment of your condition. Your medical management and/or 
follow-up care can be safely transitioned to an in-network specialist at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continuation of care with an OON pain management provider. have not been 
met. Therefore, we decided that the Plan does not have to pre-approve  a continuation of care with an out-of-
network (OON) pain management provider.