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

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for a sacroiliac joint injection.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the injection. Our reviewer says that the 
criteria for coverage has not been met. Our physician reviewer found the enrollee does not have at least 3 
positive provocative maneuvers and conservative treatment for lumbar spine and left sacroiliitis has not been 
started. Previous treatment was directed to the enrollee's thoracic spine. The enrollee was considered to start 
physical therapy for lumbosacral spine pain and left sacroiliitis. In addition, the enrollee did not have a 
diagnostic sacroiliac joint injection in the past to be considered for a therapeutic sacroiliac joint injection. The 
review has determined that the enrollee does not meet the criteria for the requested sacroiliac joint injection. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93313 billed for date of service December 14, 2022. 
 You asked the Plan to pay for code 93313. You say that this code should be paid separately. The Plan denied 
your request. The Plan says code 99313 is bundled into payment for code 00562. The Plan has approved 
payment for codes 36556 and 76937. 
 
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 93313 is a column II code to column I code 00562; however, 93313 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 93313. Our reviewer says that code 93313 is not 
separately payable. Our reviewer found the procedure report does not include sufficient documentation to 
confirm the transesophageal echocardiogram (TEE) provided was a separate distinct service from the 
anesthesia.  An interpretation and report was not found in medical record to support service provided. 
 
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 93313 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 93313 billed for date of service December 14, 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 needs extensive therapy to regain 
strength to return home. 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 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. 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) injections. 
 You asked the Plan to pre-approve the Prolia injections. You say that the enrollee has failed treatment with 
alendronate and should be approved for Prolia.  The Plan denied your request. The Plan says an injected 
bisphosphonate has not yet been tried.  
 
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 the Prolia injections. Our reviewer says 
that the requested Prolia is not reasonable and necessary based on step therapy rules.  Our physician reviewer 
found the Plan requires a trial of drug injected bisphosphonates before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating 
that the plans required drug 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 the Prolia injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Prolia (denosumab) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 12, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided on December 13, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that this device was 
provided for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a 
facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) 
provided on December 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 10, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you disagree with the 
copayment. 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 a $125 
copayment for each emergency room visit.  
 
 You have been asked to pay a $90 copayment, which is less than the standard copayment for the emergency 
room visit. This item/service falls within the emergency care 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the emergency room visit provided on January 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 7, 2022, to 
March 8, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 8, 2022. The NOA was not received by the Plan until May 3, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
February 7, 2022, to March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty (D7320) and anesthesia (D9222, and D9223).

You asked the Plan to pre-approve alveoloplasty and anesthesia . You say that this should be covered. The Plan denied your request. The Plan says this is not a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve alveoloplasty (D7320) and anesthesia (D9222, and D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 64450-59-RT billed for date of service January 6, 2023. 
 
You asked the Plan to pay for code 64450-59-RT. You say that post-operative pain management is separately 
payable. The Plan denied your request. The Plan says the use of the 59 modifier for code 64450-59-RT is not 
supported by the medical record to allow for separate payment. This code is included in code 00400. The 
records don't support that the procedure was separate or distinct.  
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 64450-59-RT Our reviewer says that 
the use of the 59 modifier to allow for separate payment of code 64450 is not supported by the medical record. 
Our physician reviewer found the medical record includes insufficient documentation to confirm this injection 
was a distinct procedure from the anesthesia provided. The documentation does not support injection for post operative pain, and therefore modifier -59 cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 64450-59-RT have not been met. Therefore, we decided that the Plan does 
not have to pay for code 64450-59-RT billed for date of service January 6, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the immunohistochemistry services provided on December 16, 2022, 
billed with diagnosis codes C43.59 and C44.619. 
 
You asked the Plan to pay for the testing as billed. You say that there is no issue with the diagnosis codes 
reported on this claim.  The Plan denied your request. The Plan says that the entire code set for C44 excludes 
the entire code set of C43, which means these diagnosis codes are not appropriate to bill together. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note in the ICD-10-CM codebook 
indicates that two conditions should not be reported together. However, if the two conditions are unrelated, an 
exception can be made. 
 
We looked at the file and Medicare rules. Review of the ICD-10-CM codebook shows that code C44 has an 
Excludes1 note for the code range of C43. However, review of the records submitted supports that these two 
conditions are unrelated. Testing was performed on two distinct specimens, and the two diagnoses reported 
correspond to the final diagnosis for each specimen. As such, the two conditions are unrelated, and it is 
appropriate for these two diagnosis codes to be reported together. Based on this information, we decided that 
Medicare rules for coverage of the testing as billed have been met. Therefore, we decided that the Plan has to 
pay for the immunohistochemistry services provided on December 16, 2022, billed with diagnosis codes 
C43.59 and C44.619.  
 
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 the evaluation and management (EM) services provided on 
January 8, 2023, billed with code 99223. 
 
You asked the Plan to pay for the EM services. You say that this should not be bundled with any other 
payment.  The Plan denied your request. The Plan says this should not have been reported as an initial code as 
another provider from the group saw the enrollee previously during this stay. 
 
The Plan must follow Medicare rules. Medicare rules say that reporting an initial EM service should be done 
only when no other provider of the same specialty from the same group has seen the enrollee during the same 
stay. 
 
 We looked at the file and Medicare rules. The provider at issue is an interventional cardiologist, and code 
99223 is for an initial EM service. The file shows that another interventional cardiologist of the same group 
saw the enrollee the day prior and was paid for an initial EM service. Based on this information, we decided 
that Medicare rules for coverage of the EM services have not been met. Therefore, we decided that the Plan 
does not have to pay for the evaluation and management (EM) services provided on January 8, 2023, billed 
with code 99223.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacituzumab govitecan-hziy (J9317). 
 
You asked the Plan to pre-approve sacituzumab govitecan-hziy. The Plan denied your request. The Plan says 
that the suggested use of the requested drug is not supported by the medical compendia.  
 
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 sacituzumab govitecan-hziy. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that there is 
insufficient evidence in the medical literature to support the use of sacituzumab govitecan-hziy in the treatment 
of refractory squamous cell carcinoma of the lung.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacituzumab govitecan-hziy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacituzumab govitecan-hziy (J9317).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 21, 2023.  
 
You asked the Plan to pay for the medical services. You say that this claim was denied incorrectly. The Plan 
denied your request. The Plan says you billed these services with an incorrect pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of E11.621 and E08.621. Code E08.621 is an Excludes1 code 
under code E11.621, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on January 21, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee feels that the therapy is 
helping them and would like to continue the therapy services.  The Plan denied your request. The Plan says that 
the additional therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has had instruction in a home exercise program. The 
requested additional therapy sessions do not require ongoing skilled professional therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services provided from October 17, 2022, 
through October 31, 2022.  
 
You asked the Plan to pay for the dialysis services. You say that this was correctly billed with all required 
modifiers. The Plan denied your request. The Plan says the modifiers to report whether ESA was given 
intravenously or subcutaneously were not reported as required.  
 
The Plan must follow Medicare rules. Medicare rules say that if an ESRD claim includes ESAs, these must be 
reported with modifier JA or JB. 
 
 We looked at the file and Medicare rules. The claim includes codes for ESA administration but does not report 
modifiers JA or JB. Based on this information, we decided that Medicare rules for coverage of the dialysis 
services have not been met. Therefore, we decided that the Plan does not have to pay for the dialysis services 
provided from October 17, 2022, through October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positive airway pressure (PAP) monitoring device 
(A9279) and power source (E1399) provided on December 9, 2022.  
 
You asked the Plan to pay for the items provided. You say that these items are medically necessary.  The Plan 
denied your request. The Plan says these items cannot be covered and are included in payment for E0601. 
 The Plan must follow Medicare rules. Medicare rules say that neither PAP monitoring devices nor alternate 
power sources are covered by Medicare.  Therefore, we decided that the Plan does not have to pay for the 
positive airway pressure (PAP) monitoring device (A9279) and power source (E1399) provided on December 
9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 27, 2023. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
February 27, 2023.