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

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99284) provided 
on July 7, 2023. 
 
You asked the Plan to pay for an emergency department visit. You say that procedure code 99284 is 
appropriate based on the level of services required. The Plan denied your request. The Plan says procedure 
code 99284 is not supported by the medical records. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 an emergency department visit. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our reviewer found the documentation 
from this date describes the enrollee with acute on chronic back pain after lifting heavy objects and complained 
of symptoms suggestive of an upper respiratory infection. The plan included antibiotics, antipyretics. The 
enrollee was stable. The documentation showed an expanded focus history and physical, not comprehensive. 
Therefore, documentation did not support a moderate level of decision making.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for an emergency department visit (procedure 99284) provided on July 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep study (95806). 
 
You asked the Plan to pre-approve a home sleep study. You say that the requested service is a necessity for 
your care. The Plan denied your request. The Plan says rules for a home sleep study have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician services related to home sleep 
testing are covered for the purpose of testing a patient for the diagnosis of obstructive sleep apnea if the home sleep testing is reasonable and necessary for the diagnosis of the patients condition, meets all other Medicare 
requirements, and the physician who performs the service has sufficient training and experience to reliably 
perform the service. Home sleep testing is not covered for persons with comorbidities. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home sleep study have not been met. Specifically, the case record indicates that you have 
comorbidities that rule out a home sleep study. Therefore, we decided that the Plan does not have to pre-
approve a home sleep study (95806).
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 an IRF level of care. The Plan 
denied your request. The Plan says medical records do not support the need for an IRF admission. The Plan 
says that the enrollee's needs can be provided at another setting. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, there is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 
15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status. The enrollee can receive further services at a lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) infusion services (96365, 96366, 96521) 
provided June 8, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 96365, 96366, 96521 is the definition of code 96365 is 
intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour. 
The definition of code 96366 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance 
or drug); each additional hour (List separately in addition to code for primary procedure). The definition of 
code 96521 is refilling and maintenance of portable pump.   
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 the services. Our reviewer found for codes 96365 and 96366, 
there is not procedure note or start or stop that the infusion took place, only an order. As for the 96521 there is 
no notation that the refilling and maintenance was performed on the pump. 
 
We looked at this coder's review, the file, and Medicare rules. 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 intravenous (IV) infusion services (96365, 96366, 96521) provided June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0483) provided April 5, 
2023.  
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the current documentation does not include the order. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 80307 and G0483 is not supported in the medical record. Specifically, the current 
documentation does not include the order. In order to validate services billed, the order, laboratory report and 
method of testing should be documented within the medical record. 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 laboratory services (80307 and G0483) provided April 5, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the request is medically necessary. The Plan denied 
your request. The Plan says that Keytruda is not considered medically necessary for the enrollee's indication. 
 
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 Keytruda. Our reviewer says that the 
requested use of Keytruda is supported. Our physician reviewer found vaginal cancer is treated similar to 
cervical cancer. The documentation supports that the requested drug is safe and effective and otherwise 
reasonable and necessary for this 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda (J9271).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Onivyde. 
 
You asked the Plan to pre-approve Onivyde. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, 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 Onivyde. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the NAPOLI-1 phase 3 study demonstrated 
survival benefit using liposomal irinotecan + Leucovorin + 5-FU. The liposomal irinotecan was dosed at 80 
mg/m^2 as requested by the provider. The requested drug is demonstrated it to be safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Onivyde have been met. Therefore, we decided that the Plan has to pre-approve 
Onivyde.  
 
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 pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the records provided support the need for 
the injection services being requested. The Plan denied your request. The Plan says the criteria for coverage 
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 facet joint injections. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back due to degenerative disc disease. The note describes radicular 
pain and associated numbness in his feet. He is using a brace, oxycodone and has had trigger point injections. 
Coverage criteria excludes patients with radicular symptoms from receiving diagnostic facet blocks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the external mobile cardiovascular telemetry (93228 and 93229) 
provided July 13, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 93228 is external mobile cardiovascular telemetry with electrocardiographic recording, concurrent 
computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with 
query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for 
up to 30 days; review and interpretation with report by a physician or other qualified health care professional. 
The definition of code 93229 is external mobile cardiovascular telemetry with electrocardiographic recording, 
concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage 
(retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended 
surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended 
surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other 
qualified health care professional. 
 
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 the services. Our reviewer found the documentation does 
support that codes 93228 and 93229 were 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 the services have been met. Therefore, we decided that the Plan has to pay for 
the external mobile cardiovascular telemetry (93228 and 93229) provided July 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on May 31, 2023. 
 
You asked the Plan to pay for the UDT for 22 or more drug classes. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management and exceeds the needs of the member. 
Under Medicare rules, the number of definitive urine drug classes requested 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 pay for the UDT for 22 or more drug classes. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has chronic pain. She is taking Percocet and Lyrica. The enrollee 
had quantitative testing on 22 drug classes. There is no documentation of qualitative testing or of diversion or 
abuse of the medications. 
 
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 UDT for 22 or more drug classes have not been met. Therefore, we decided 
that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes (G0483) 
provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator (E0748). You say that the 
requested spinal electrical osteogenesis stimulator (E0748) is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for a spinal electrical osteogenesis stimulator 
(E0748). 
 
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 spinal electrical osteogenesis 
stimulator (E0748). Our reviewer says that the enrollee does not meet criteria for a spinal electrical 
osteogenesis stimulator (E0748). Our physician reviewer found there is no documentation of fusion failure. 
There are not 3 or more spinal levels fused in surgery. 
 
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 spinal electrical osteogenesis stimulator (E0748) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator 
(E0748).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 27, 
2023, to August 4, 2023. 
 
You asked the Plan to pay for SNF care. You say that the records provided support the medical necessity of the 
SNF care in dispute. The Plan denied your request. The Plan says the SNF services provided do not meet the 
requirements for approval. 
 
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 the enrollee did not have skilled nursing needs.  The enrollee did not have skilled 
therapy needs.  The enrollees needs were custodial and could, as a practical matter, be provided at a lower 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from July 27, 2023, to August 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0482) provided April 5, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
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, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the code billed is incorrect 
as the amount of drug classes tested do not match the range on the billed code. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing (G0482) provided April 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service January 21, 
2023. 
 
You asked the Plan to pay for procedure code 76140. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service January 21, 2023.