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

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 4, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that this should be paid for. The Plan denied your 
request. The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 4, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits (G0299 x4).  

You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
records did not show that more than the 2 already approved additional skilled nursing visits were required for 
this enrollee to further improve the enrollee's condition or to help maintain the program instructed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 home health skilled nursing visits (G0299 x4).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary because the records show the vertebral compression 
fracture has moderate retropulsion, which is a relative contraindication for the procedure. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 T12 kyphoplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is 
not evident regarding documentation of a progression of the body height loss, or kyphotic deformity. 
Moreover, there is magnetic resonance imaging corroboration of retropulsion and other plausible causes of 
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 T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22513).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).

You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that you have multiple sclerosis and need a powered wheelchair to get around. The Plan denied your request. The Plan says based on Medicare guidelines, the power wheelchair (K0823) that you are requesting does not meet the requirements for approval.

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 group 2 standard power wheelchair have been met. Specifically, records of an on-site evaluation were not provided and is required for coverage. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the requested left heart 
catheterization is medically necessary. The Plan denied your request. The Plan says the requested left heart 
catheterization does not meet the Medicare 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 left heart catheterization. Our reviewer 
says that the requested left heart catheterization is not considered medically necessary and reasonable in this 
case. Our physician reviewer found the enrollee with no angina and normal noninvasive studies does not benefit from invasive coronary angiogram. The enrollee with normal peripheral pulses, no claudication, no 
non-healing ulcers or resting pain related to peripheral arterial disease does not benefit from aortogram with 
runoffs angiography. Both these test are invasive and involve contrast and radiation and they can in fact harm 
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 left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service June 26, 
2023.   
You asked the Plan to pay for procedure code 88342. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88342 is 4. The MAI value for this code is 3. You billed 9 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88342 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88342 billed for date of service June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service February 28, 
2023. 
 You asked the Plan to pay for procedure code 93010. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 
31500. 
 
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 93010 
is a column II code to column I code 31500. 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 93010 billed for date of service February 28, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 11, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from July 3, 2022, to July 22, 
2022. 
 
You asked the Plan to pay for the inpatient stay. You say that this inpatient admission was medically necessary 
for the enrollee, and you would like the previous denial to be overturned. The Plan denied your request. The 
Plan says the inpatient hospital admission from July 10, 2022, forward was not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 stay. Our reviewer says that this 
request is not medically necessary. Our physician reviewer found the documentation did not state that the 
enrollee was not stable enough for transfer on any of the days between July 11, 2022, and July 22, 2022. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from July 3, 2022, to July 22, 2022.
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 the record indicates that the enrollee has ongoing 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 they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that a kyphoplasty is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says a kyphoplasty 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 a kyphoplasty. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident in the case record regarding the L4 fracture being acute or 
subacute (as it was present on the imaging study performed on February 17, 2023). Additionally, there is no 
documentation of a progression of the body height loss, greater than 25% vertebral body height loss, kyphotic 
deformity or a severe impact on daily activities. Moreover, there is magnetic resonance imaging (MRI) scan 
corroboration of other plausible causes of 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 a kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty procedure (22514).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 81321 and 81309 billed for date of service April 19, 
2023. 
 
You asked the Plan to pay for procedure codes 81321 and 81309. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that these codes were not billed 
with a diagnosis code which supports medical necessity per Local Coverage Article: Billing and Coding: 
Molecular Pathology Procedures (A56199). 
 
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. Specifically, the Local Coverage Article cited by the Plan does list diagnosis 
codes which are generally considered medically necessary for these laboratory procedure codes. This article 
also has a list of diagnosis codes which are explicitly non-covered for all molecular pathology procedures. The 
diagnosis code reported on this claim does not fall on either list. This does not mean this diagnosis is 
automatically denied as the Plan states, rather, it would be subject to medical necessity review. The Plan did 
not perform this review. The Plan has not substantiated their denial in this case. Therefore, we decided that the 
Plan has to pay for procedure codes 81321 and 81309 billed for date of service April 19, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup services for tooth #18 (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
 
  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 dental services. Our physician 
reviewer found that the record indicates there is sufficient tooth structure to retain a crown without a core 
buildup. The requested services are not recommended at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve core buildup services for tooth #18 (D2950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81551) provided on March 15, 2023. 
 
You asked the Plan to pay for genetic testing. You say that the genetic testing was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the genetic test at issue 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 genetic testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the molecular test needed to be performed either pre-biopsy or post-biopsy when there is 
consideration for a repeat biopsy due to continually elevated Prostate Specific Antigen (PSA) or abnormal 
Digital Rectal Exam (DRE). Instead, the molecular testing at issue was ordered in conjunction with the first 
biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing (81551) provided on March 15, 2023.
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 enrollee qualifies for an LTACH 
level of care. You say you would like to request authorization for an LTACH admission versus staying at the 
short term acute care hospital. The Plan denied your request. The Plan says the LTACH services requested do 
not meet the requirements for approval. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital. 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 18, 2023. 
 
You asked the Plan to pay for the lab services. You say that the coding of the lab services is valid, and this 
testing was ordered by the patient's treating physician. The Plan denied your request. The Plan says you billed 
with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that without non-invasive ventilator (NIV) 
therapy, this patient is at high risk for hospital readmission and potentially life-threatening exacerbations. The 
Plan denied your request. The Plan says based on Medicare guidelines, the NIV requested does not meet the 
requirements for approval.  
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that this request is not medically necessary. Our physician reviewer found the record indicates that the patient 
has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. Our reviewer also found that the patient could be treated with a BiPAP machine with average volume-
assured pressure support (AVAPS) capability and failure of such a device has not been documented.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).