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

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
January 25, 2023. 
 You asked the Plan to pay for procedure codes 88341 and 88342. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says payment for codes 88341 
and 88342 is bundled into payment for code 88360. 
 
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 
88341 and 88342 are column II codes to column I code 88360. 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 codes 88341 and 88342 billed for 
date of service January 25, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrode array 
(64555). 
 
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not 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 pre-approve the services. Our physician reviewer 
found the enrollee has a specific peripheral neuropathy and meets the indication for the placement of this 
device; therefore, the request is 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve percutaneous implantation of neurostimulator electrode array (64555).  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the oncology services provided on November 11, 2022. 
 
You asked the Plan to pay for the oncology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the claim was denied stating The member's Plan excludes 
coverage for charges for, or in connection with, services or supplies that we determine to be experimental, 
investigational, cosmetic or not generally recognized according to professional standards of safety and 
effectiveness in the United States for diagnosis, care, or treatment." 
 
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 did not substantiate what codes were denied. The Explanation of 
Benefits (EOB) does not show the services that were being billed. Therefore, we decided that the Plan has to 
pay for the oncology services provided on November 11, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are having a very hard time getting your 
strength back and not strong enough to be home alone. The Plan denied your request. The Plan says you do not 
require complex daily nursing care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), 
and electronic connection (E2311). 
 
You asked the Plan to pre-approve the expandable controller, harness, and electronic connection. 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 expandable controller, harness, and 
electronic connection. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee's upper extremity strength and tone are 
normal per the nurse practitioner note. Also, the functional ability as evidenced by being independent in catheterization should be sufficient to control any power options through their own switches. 
 
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 expandable controller, harness, and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2377), 
harness (E2313), and electronic connection (E2311).
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not reasonable and necessary, as 
the enrollee's condition does not meet Medicare rules.  
 
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 the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee 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 the enrollee 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
(87798, 87801) provided on March 30, 2023. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necesary. The 
Plan denied your request. The Plan says this panel should not be unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test must not be 
unbundled and billed as individual components regardless of the fact that the panel reports multiple individual 
pathogens and/or targets. 
 
We looked at the file and Medicare rules. In this case the testing was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the respiratory PCR panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory polymerase 
chain reaction (PCR) panel (87798, 87801) provided on March 30, 2023.
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 you are requesting IRF services so you can progress 
as quickly as possible and get home independently. You also say you will need intravenous antibiotics that will 
need to be closely managed by a doctor. The Plan denied your request. The Plan says you do not meet 
Medicare guidelines for services in 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 You asked the Plan to pre-approve Evenity. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says the step therapy requirements have not been met. 
 
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 Evenity. Our reviewer says that the step 
therapy requirements have not been met. Our physician reviewer found that the Plan requires a trial of drug, 
Forteo, before they will approve the requested drug, Evenity. In this case, the enrollee has not tried and failed 
the required drug. There is no documentation provided indicating that Forteo would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 4, 2022, billed with 
codes 81225, 81226, 81227, 81231, 81240, 81241, 81291,81328, 81335, 81401, 81306 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that please see attachment and reprocess the 
claim. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the 
claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 4, 2022, billed with codes 81225, 81226, 81227, 81231, 81240, 81241, 81291,81328, 81335, 81401, 
81306 and 81355.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 25, 2022, billed 
with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87661, 87481, 87651 and 87653. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are an independent diagnostic 
laboratory that tests pathology, medication management and toxicology samples sent from clinics and 
providers for patients they have determined require testing. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 25, 2022, billed with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87661, 
87481, 87651 and 87653.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis codes A40.8 
and E87.2 rendered from March 16, 2022, to March 24, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim were supported clinically. 
 
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 DRG 872. 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 reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that there was insufficient support made for a systemic infection or sepsis. Sepsis 3 criteria was not met as there 
was no evidence of a dysregulated response leading to life-threatening organ failure. Also, based on resolution 
of acidosis after fluids and medication changes prior to admission, the diagnosis of acidosis is also not 
sufficiently supported. Therefore, the codes, A40.8 and E87.2 are each not supported in the provided 
documentation for this admission, and therefore, the DRG 312 is more appropriate.  
 
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 billed with diagnosis codes A40.8 and E87.2 rendered from March 16, 2022, to 
March 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on March 21, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs 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. The total allowed amount for the prescription drugs is $274.83. You are 
being asked to pay $49.56 ($274.83 x 20% = $49.56). Therefore, we decided that the Plan does not have to 
waive the coinsurance for Medicare Part B prescription drugs provided on March 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code S2900. 
 
You asked the Plan to pre-approve procedure code S2900. You say that the use of a robot/laparoscopy will be 
the most minimally invasive for the enrollee. You also say that this will result in less recovery time for the 
enrollee. The Plan denied your request. The Plan says the requested code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve procedure code S2900.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammography (77067) and related services 
(77063) provided on December 8, 2022. 
 
You asked the Plan to pay for a screening mammography and related services. You say that the services at 
issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 
for screening mammography have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for a screening 
mammography performed on a woman under age 35. Payment may be made for only one screening 
mammography performed on a woman over age 34, but under age 40. For an asymptomatic woman over age 
39, payment may be made for a screening mammography performed after at least 11 months have passed following the month in which the last screening mammography was performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a screening mammography and related services have not been met. Specifically, the case record 
does not support that as of the date of service at issue, at least 11 months had passed following the month in 
which the last screening mammography was performed. Therefore, we decided that the Plan does not have to 
pay for a screening mammography (77067) and related services (77063) provided on December 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee wants to get in and out of rehabilitation 
as fast as possible. The Plan denied your request. The Plan says it is not necessary for the enrollee to be 
admitted into an Acute Rehabilitation Facility at this time. 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.