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

 
We decided that the Plan does not have to pay for magnetic-resonance contrast-agent injection (A9579) billed 
for date of service March 28, 2023. 
 
You asked the Plan to pay for magnetic-resonance contrast-agent injection. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided records do not support the 
code billed. 
 
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 A9579 is: Injection, gadolinium-based magnetic 
resonance contrast agent, not otherwise specified (NOS), per ml. 
 
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 magnetic-resonance contrast-agent injection. Our reviewer 
says that procedure code A9579 does not meet criteria for payment. Our reviewer found that the procedure 
report documents "Long- and short-axis fat- and water weighted images were obtained before and after contrast 
administration." The laboratory report does not include sufficient documentation to verify the procedure code 
billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic-resonance contrast-agent injection have not been met. Therefore, we 
decided that the Plan does not have to pay for magnetic-resonance contrast-agent injection (A9579) billed for 
date of service March 28, 2023.
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 services are medically necessary to give the 
enrollee the best opportunity at being able to return home at their previous level of function. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 9, 2023, to January 10, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you think that the 
copayment is too high. 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 $310 
copayment each day, for days 1 to 5, for Medicare-covered hospital care each time you are admitted. 
 
 You have been asked to pay a $310 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital 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 inpatient 
hospital stay provided from January 9, 2023, to January 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan of the leg to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the CT scan. You say that your provider needs this scan before they can 
perform your surgery. The Plan denied your request. The Plan says there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computerized tomography (CT) scan of the leg to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 pre-approve 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and skilled therapy on an inpatient basis in a skilled nursing facility (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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that the requested drug is a medical necessity 
for the enrollee. 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Repatha 
Sureclick.  
 
Benefits for Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve individual treatment of speech, language, voice (92507). 
 
You asked the Plan to pre-approve the therapy services. You say that clinical information was submitted with 
the appeal request to support medical necessity for the enrollee. The Plan denied your request. The Plan says 
there is no clinical evidence to support the medical necessity of this the device or that the enrollee meets 
Medicare criteria.  
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 the enrollee has previously been treated with outpatient therapies and 
should be independent with a home program.  The additional therapy services are not an appropriate duration 
and frequency for treatment of the enrollees medical condition. 
 
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 individual treatment of speech, language, voice (92507).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that Prolia is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Prolia have not been met. 
 
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 treatment 
with Prolia is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a history of osteoporosis-related fracture or a trial of drug zoledronic acid before they will approve the 
requested drug, Prolia. Based on the medical records provided, there is no indication of osteoporosis-related 
fracture or that the enrollee has tried and failed the required drug. Based on the medical records provided and 
the Medicare-approved major drug compendia, there is no indication that the Plan's 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code Q5106. We decided that the Plan does not have to pay 
for procedure codes 96372, 80048, 80076, 83550, 83540, 82728, and 85025.  
 
You asked the Plan to pay for procedure codes Q5106, 96372, 80048, 80076, 83550, 83540, 82728, and 85025 
provided on January 23, 2023. You say that you would like the Plan to reconsider their denial of payment. The 
Plan says that the only service that had been approved was procedure code Q5106. 
 
We decided that the Plan has to pay for procedure code Q5106.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has confirmed in the file that procedure code Q5106 had 
already been approved and there is no reason provided why the approved code was not paid for. Therefore, we 
decided that the Plan has to pay for procedure code Q5106.  
 
We also decided that the Plan does not have to pay for procedure codes 96372, 80048, 80076, 83550, 
83540, 82728, and 85025. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for procedure codes 96372, 80048, 80076, 83550, 
83540, 82728, and 85025. 
 
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 additional SafeRide mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you will need to have a procedure done as 
soon as possible to prevent severe damage to the back of your eyes. You will need transportation for this 
procedure. The Plan denied your request. The Plan says you are requesting an additional 3 miles for a total of 
53 miles and your benefit only allows 50 miles. The Plan also says you have exceeded your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 48 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional SafeRide mileage 
(A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (87631) and noninvasive ear or pulse 
oximetry for oxygen saturation (94761) provided on July 7, 2022. 
 
You asked the Plan to pay for laboratory testing and measure of oxygen level. You say that you disagree with 
the denial and request payment on this claim. The Plan denied your request. The Plan says code 87631 did not 
include the required unique identifier. The Plan also says that payment for code 94761 is bundled into payment 
for code 94664. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported for code 87631. Based on this information, we decided that Medicare rules for coverage of code 
87631 have not been met. We also find that procedure code 94761 has a status indicator of T on the Physician 
Fee Schedule. This means that they are only paid if there are no other services payable under the physician fee 
schedule billed on the same date by the same provider. Code 94664 was billed on the same day, by the same 
provider, therefore, these services are bundled into the physician services for which payment is made. Code 
94761 is not payable. Therefore, we decided that the Plan does not have to pay for laboratory testing (87631) 
and noninvasive ear or pulse oximetry for oxygen saturation (94761) provided on July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing panel provided on March 31, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays 2 or more genes in a patient 
in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so 1 HCPCS codes must be submitted for the panel.  
 
We looked at the file and Medicare rules. In this case, the panel was billed with multiple codes and not one unit 
of one code as required by LCA A58120. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
testing panel provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37225 and 99152 billed for date of service 
January 23, 2023. 
 
You asked the Plan to pay for procedure codes 37225 and 99152. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the provided records do not support the codes 
reported. 
 
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 37225 is: Revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same 
vessel, when performed. The definition of code 99152 is: Moderate sedation services provided by the same 
physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 
years or older. 
 
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 procedure codes 37225 and 99152. Our reviewer says that 
procedure codes 37225 and 99152 do not meet criteria for payment. Our reviewer found that with regard to 
procedure code 37225, the procedure report does not include documentation of atherectomy. There is a more 
appropriate code to report for balloon angioplasty. With regard to procedure code 99152, the provided medical 
records neither described or identified an independent trained observer to assist in the monitoring of the 
enrollee's level of consciousness and physiological status during the procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 37225 and 99152 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 37225 and 99152 billed for date of service January 23, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel provided on November 3, 
2022. 
 
You asked the Plan to pay for the urinary tract infection panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says there is a lack of data to suggest these panels alter 
medical decision making. 
 
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 urinary tract infection panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the standard of care for diagnosing a urinary tract infection remains 
urinalysis with urine culture. Regarding urinary tract infection panels, there is a lack of data to suggest these 
panels alter medical decision making. In summary, the requested testing exceeded the enrollees medical needs. 
The review has determined that the items/services at issue in this case were 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 the urinary tract infection panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the urinary tract infection panel provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service January 7, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records do support the level of care. 
The Plan denied your request. The Plan says the billed code is 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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 We find that CPT code 99223 is not supported in the medical record. The records show that the enrollee was 
alert, in no acute distress, with unlabored breathing and a regular heart rate. The enrollee was admitted as an 
inpatient for monitoring and consultations with cardiology and urology. The records do not support a high level 
of medical decision making. The records do not include the total time on the date of service at issue. 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 procedure code 99223 billed for date of service 
January 7, 2023.