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

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that Evenity is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
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 Evenity. Our reviewer says that Evenity 
is not medically necessary. Our physician reviewer found Evenity is only indicated to be used for treatment of 
osteoporosis in postmenopausal women. The requested use is not an FDA approved indication. 
 
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.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on December 16, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and were reported 
correctly. The Plan denied your request. The Plan says that the code used in this case does not accurately reflect 
the services provided. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records provided support 
that drugs from 18 different drug classes were tested in this case. Based on this information, we decided that 
Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for 
definitive drug testing (G0482) provided on December 16, 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services rendered from February 12, 2021, to March 
11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the reversal is due to a resubmission/change to the claim by the provider. 
 
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 states that payment was reversed due to a resubmission/change to the 
claim by the provider; however, the Plan has not provided further documentation or information regarding this 
change. There is no clear documentation to support that the claim is not payable per Medicare rules. Therefore, 
we decided that the Plan has to pay for the home health services rendered from February 12, 2021, to March 
11, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at L1. 
 
You asked the Plan to pre-approve a surgical procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the medical criteria for this surgery have not been met. 
 
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 surgical procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are plausible other causes of pain in the lumbar spine demonstrated on the 
magnetic resonance imaging (MRI). 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty at L1.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for shipboard emergency room services (82962, 36000, 8005, 80061, 
93000, 96372, 99283, 85610, 80048, 80050,  
85610, 93000, 84484, 94799, J3490)  provided on December 4, 2022. 
 
You asked the Plan to pay for the emergency services.. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that they were unable to review the appeal in the allowed timeframe. 
 
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 original denial notice states this service was included in another service 
billed. The plan did not provided documentation to show which services were included in another service. The 
plan did not fully articulate the reason for the denial. Therefore, we decided that the Plan has to pay for 
shipboard emergency room services (82962, 36000, 8005, 80061, 93000, 96372, 99283, 85610, 80048, 80050,  
85610, 93000, 84484, 94799, J3490)  provided on December 4, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) provided on December 15, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were performed as ordered and are 
supported as billed. The Plan denied your request. The Plan says there is insufficient information to support 
that these services were necessary and were ordered by a physician who is treating the enrollee. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 drug testing have been met. 
Specifically, the provider signature on the test requisition/order form is illegible, and there are no physician 
notes included in the documentation to support that the enrollee's treating physician had intent for this test to be 
performed and support the medical necessity of these services. Therefore, we decided that the Plan does not 
have to pay for drug testing (G0482) provided on December 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided November 28, 
2022, to November 29, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says the medical criteria for an inpatient admission were not 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided November 28, 2022, to November 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy (HBOT) with physician 
supervision for 20 sessions (99183, G0277). 
 
You asked the Plan to pre-approve HBOT with physician supervision. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBOT with physician supervision. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the review has 
determined that HBOT must be an adjunctive therapy to standard wound therapy including antibiotics and 
wound debridement. The review indicates that the enrollee does not meet the coverage criteria detailed in the 
NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT with physician supervision have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy (HBOT) with physician supervision for 
20 sessions (99183, G0277).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LinQ procedure (0775T). 
 
You asked the Plan to pre-approve a LinQ procedure. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 v a LinQ procedure. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found no compelling rationale is presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested LinQ Procedure, in this case, is not medically 
reasonable or 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  a LinQ procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a LinQ procedure (0775T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on March 6, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (J3490) is included in the global 
surgery payment for the procedure (64490) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drugs (J3490) provided on March 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left atrial appendage closure (LAAC). 
 
You asked the Plan to pre-approve LAAC procedure. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the record does not show that the enrollee has had a formal shared 
decision making interaction with an independent non-interventional physician using an evidence-based 
decision tool on oral anticoagulation in patients with atrial fibrillation. 
 
The Plan follows Medicare rules. Medicare rules state that left atrial appendage closure (LAAC) may be 
covered through coverage with evidence development (CED) if certain 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 LAAC procedure. Our reviewer says 
that the enrollee does not meet criteria for this procedure. Our physician reviewer found there is no 
documentation of performance of an evidence-based shared decision-making interaction on anticoagulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LAAC procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve left atrial appendage closure (LAAC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 6, 2021, to July 
9, 2021, 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 N17.9, described as 
Acute kidney failure, unspecified. 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 is an 80-year-old male with chronic kidney disease who 
presented to the emergency department with bradycardia and was found to have creatinine 1.93 mg/dl. He was 
initially treated with fluids. Follow-up creatinine levels were 1.44, 1.32, and 1.51 mg/dl. The documentation 
did not sufficiently support the diagnosis of acute kidney failure (N17.9) as there was not a significant rise of 
1.5 times the patient's baseline creatinine or rise of 0.3 creatinine within 48 hours or a significant oliguria noted 
during the hospital stay to meet the definition of acute kidney 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 July 6, 2021, to July 9, 2021, at the Diagnosis Related Group (DRG) 
originally billed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from May 19, 2022, to June 17, 2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs  
 
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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a 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 pay for SNF care provided from May 19, 2022, to June 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve. 
 
You asked the Plan to pre-approve a surgery. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the medical criteria for the requested services have not been met. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the cause of the back is not clear. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a thermal destruction of intraosseous basivertebral nerve.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nerve ablation procedure (64640). 
 
You asked the Plan to pre-approve nerve ablation procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 nerve ablation procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy as the long-term outcomes are not known. 
The request is not 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 nerve ablation procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nerve ablation procedure (64640).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records indicate no symptoms and thus do not support the rationale for this 
invasive imaging study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930, 20936 and 22845 billed for date of 
service September 30, 2022. 
 
You asked the Plan to pay for procedure codes 20930, 20936 and 22845. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says payment for code 22845 is 
bundled into payment for code 22853. In addition, codes 20930 and 20936 are always bundled. 
 
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 22845 is a column II code to column I code 22853. This claim has 
not been billed with an appropriate modifier to bypass the edit. In addition, we find that procedure codes 20930 
and 20936 both have a status indicator of B on the Physician Fee Schedule. This means that codes 20930 and 
20936 are not separately payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 20930, 20936 and 22845 billed 
for date of service September 30, 2022.