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

 
We decided that the Plan does not have to pay for  the lab testing billed for date of service August 1, 2022. 
 
You asked the Plan to pay for  the billed services. You say that the pathology report was provided.  The Plan 
denied your request. The Plan says the service is excluded from coverage.  The Plan must follow Medicare rules. Medicare rules say that lab testing is only covered under certain medical 
indications.  
 
We looked at the file, and Medicare rules. The records provided shows that the testing was used to validate a 
specimens purity. The results of the testing would not be used in the management of a specific medical 
problem. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for  the lab testing billed for date of service 
August 1, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 81270, 81339, and 81219. We decided that the Plan 
does not have to pay for procedure codes 88342, 88291, 88377, and G0452.  
 
You asked the Plan to pay for the lab testing billed for date of service November 23, 2022.. You say that the 
modifier requirements are followed. The Plan says that the codes cannot be separately reimbursed.  
 
We decided that the Plan has to pay for procedure codes 81270, 81339, and 81219.  
 
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. 
 
We looked at the file and the rules. The Plan originally denied services as the records do not support the 
services billed. The medical records do show that the testing services were provided. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for procedure codes 81270, 81339, and 81219.  
 
We also decided that the Plan does not have to pay for procedure codes 88342, 88291, 88377, and G0452. 
 
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.   
 
The file shows that codes 88342, 88291, 88377, and G0452 were billed with the -59 modifier. The medical 
records provided do not show that the service billed with the -59 modifier were distinct procedural services. 
The -59 modifier should not be appended to a code just to bypass an edit. Based on this information, we 
decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 88342, 88291, 88377, and G0452. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on December 21, 2022. 
 
You asked the Plan to pay for genetic testing. You say that these services were medically necessary. 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 genetic testing provided 
on December 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 25, 2022, at 
the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 secondary diagnosis code A41.9, described as 
Sepsis, unspecified organism. 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 documentation does not support the billed 
code. Our physician reviewer found the enrollee presented with abdominal pain, drainage from an old surgical 
incision and recently identified progressive metastasis. She was found to have an abdominal wall abscess and 
an infected port. The abscess was drained, the port was removed, and antibiotics/antifungals were provided. 
There is no evidence that the enrollee had sepsis (hypotension, hypoperfusion, organ failure).    
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 25, 2022, at the Diagnosis Related Group (DRG) originally 
billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug (A9270) provided on November 
14, 2022. 
 You asked the Plan to pay for the medication. You say that your doctor did not give you a prescription or any 
drug to take. You also say that your provider advised they did not do a procedure to require this this 
medication. 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. Additionally, there were no medical records provided to support that there was no self-
administered medication given on the date of service in this case. Therefore, we decided that the Plan does not 
have to pay for the self-administered drug (A9270) provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve an implant. 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 Plans 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 
implant supported porcelain/ceramic crown (D6065).
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. The Plan denied your request. The Plan says an inpatient 
rehabilitation admission is not supported from the records received. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam image (D0380). 
 
You asked the Plan to pre-approve cone beam image. 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 Plans 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 
cone beam image (D0380).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a DEXCOM G7 receiver null device. 
 
You asked the Plan to pre-approve a DEXCOM G7 receiver null device. You say that your transmitter is not 
working correctly, and you need another one early. The Plan denied your request. The Plan says that you do not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a DEXCOM G7 receiver null device. 
Our reviewer says that you need this medical item. Our physician reviewer found you are switching to a new 
CGM system that does not require a transmitter. You need the g7 sensors and reader for this. You are on a 
metered dose inhaler (mdi) adjusting your Lyumjev doses according to blood glucose (bg) and likely your food 
intake. Therefore, criteria has been met.  
 
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 DEXCOM G7 receiver null device have been met. Therefore, we decided that 
the Plan has to pre-approve a DEXCOM G7 receiver null device.  
 
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 custom fabricated abutment  includes placement 
(D6057), and abutment supported porcelain/ceramic crown (D6058) for tooth #29. 
 
You asked the Plan to pre-approve the dental services represented by codes D6057 and D6058. You say that 
your coverage is $5,000 and you have not reached the limit for the Plan to deny. You also say that you were not 
informed of the dental limits for this year and you need this treatment The Plan denied your request. The Plan 
says your benefit for the requested services has already been exhausted. 
 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on date of service February 18,2023. Therefore, 
we decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement 
(D6057), and abutment supported porcelain/ceramic crown (D6058) for tooth #29.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a history of osteoporosis. The documentation does not support that the enrollee has a 
history of osteoporotic fracture or has tried and failed zoledronic acid. The documentation does not support that 
zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services. 
 
You asked the Plan to pay for the mental health services. You say that you need this service. The Plan denied 
your request. The Plan says the requested provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the mental health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care (99220), and medical vision 
examination and evaluation, with initiation or continuation of diagnostic and treatment program (99053) 
provided on April 20, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the claim was submitted within payer limits 
and proof is provided. The Plan denied your request. The Plan says the corrected claim was not provided 
timely. 
 
The Plan follows Medicare rules. The rules say that a party may request a contractor reopen and revise its 
initial determination within 1 year from the date of the initial determination or redetermination for any reason.  
The record shows that a corrected claim for the outpatient services was not filed until January 3, 2023. This 
means that more than one calendar year from the initial determination had passed before a corrected claim was 
filed. Therefore, we decided that the Plan does not have to pay for the initial observation care (99220), and 
medical vision examination and evaluation, with initiation or continuation of diagnostic and treatment program 
(99053) provided on April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel release and median nerve neuroplasty 
(identified with codes 29848 and 64721). 
 
You asked the Plan to pre-approve carpal tunnel release and median nerve neuroplasty. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services 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 carpal tunnel release and median nerve 
neuroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case.  Our physician reviewer found the enrollee was being treated for primary osteoarthritis 
of the left shoulder; radial styloid tenosynovitis; primary osteoarthritis of the right wrist; carpal tunnel syndrome of the right upper limb. Conservative treatment included a right basilar joint injection. There is no 
instability of the first carpometacarpal joint, but there is pain. Finkelsteins is positive. The enrollee has no 
intercarpal laxity on stress. Tinels is negative as is wrist compression test. However, detailed documentation 
regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is 
not evident for carpal tunnel. Although peer-reviewed literature does support the necessity of electrodiagnostic 
testing in carpal tunnel syndrome in cases of clear-cut clinical carpal tunnel syndrome; the current exam does 
not support clear-cut objective findings supporting carpal tunnel syndrome. No compelling rationale is 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of carpal tunnel release and median nerve neuroplasty have not been met. 
Therefore, we decided that the Plan does not have to pre-approve carpal tunnel release and median nerve 
neuroplasty (identified with codes 29848 and 64721).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on March 26, 2022 to 
April 1, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
strongly disagree with the continued auditor recommendation to remove code E87.1, and are requesting an 
appeal redetermination. The Plan denied your request. The Plan says DRG 543 is not supported as the 
diagnosis of Hypo-osmolality and hyponatremia. 
 
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 diagnosis code, E87.1, defined as Hypo-osmolality 
and hyponatremia. 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 submitted DRG is not supported. Our 
physician reviewer found the enrollee was admitted to the hospital for acute spinal compression fracture 
following a mechanical fall. Labs revealed sodium 130 millimoles (mmol) per litre and glucose 115 milligrams 
per decilitre. Our reviewer found that repeat labs on day one showed sodium level up to 136 mmol following 
initial treatment with intravenous fluids. There was no evidence that the enrollee had a specific cause of 
hyponatremia that was not resolving on admission. Our physician reviewer found that therefore, the provided 
documentation does not sufficiently support the diagnosis of hypo-osmolality and hyponatremia (E87.1) for 
this admission.   
 
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 the inpatient hospital services provided on March 26, 2022 to April 1, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a history of knee pain due to osteoarthritis of the knee. The documentation does not 
support that the enrollee has tried and failed Orthovisc or Supartz FX. The documentation does not support that 
Orthovisc or Supartz FX would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service June 15, 
2022. 
 You asked the Plan to pay for the billed service. You say that the claim was inappropriately down coded.  The 
Plan denied your request. The Plan says the code remains not supported.  
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the medical records provided do not include a critical care note from the billed 
rendering provider for the date of service at issue. Based on this information, we decided that Medicare rules 
for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99291 billed for date of service June 15, 2022.