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

 
We decided that the Plan does not have to pre-approve insertion or replacement of peripheral or gastric 
neurostimulator pulse generator or receiver, direct or inductive coupling (64590). 
 
You asked the Plan to pre-approve insertion or replacement of peripheral or gastric neurostimulator pulse 
generator or receiver, direct or inductive coupling. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that patients must have undergone careful screening, 
evaluation and diagnosis by a multidisciplinary team prior to implantation. This screen must include 
psychological, as well as physical evaluation. 
 
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 insertion or replacement of peripheral 
or gastric neurostimulator pulse generator or receiver, direct or inductive coupling. Our reviewer says that the 
documentation provided did not demonstrate that the criteria for coverage was met. Our physician reviewer 
found there is no evidence of a psychological evaluation having been undergone by 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 insertion or replacement of peripheral or gastric neurostimulator pulse generator 
or receiver, direct or inductive coupling have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, 
direct or inductive coupling (64590).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the myocardial strain imaging (93356). 
 
You asked the Plan to pre-approve the myocardial strain imaging. You say that the imaging is medically 
necessary. The Plan denied your request. The Plan says the requested imaging 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 the myocardial strain imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is insufficient support in the peer-reviewed literature demonstrating a significant benefit of such imaging of the heart in guiding optimal management of this patient. 
As such, myocardial imaging using speckle tracking is considered experimental/investigational for the 
evaluation and management of this patient's 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 myocardial strain imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the myocardial strain imaging (93356).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 24, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that 70450 should be paid as billed because it is 
supported in the documentation, and the enrollee had multiple exams on the same date of service. The Plan 
denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 70450 billed for date of service May 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection provided on June 24, 
2021. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that this bill is from two years ago 
and you do not know why you would owe this amount. 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 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay $27.71, which is 20% coinsurance of the allowed amount for the drug injection 
($138.53 allowed amount x 20% coinsurance = $27.71). This item/service falls within the Medicare Part B 
drugs 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 coinsurance for the drug injection provided on 
June 24, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there is no medical complexity noted. There are no acute rehab nursing needs 
documented. The enrollee does not need physician supervision 3 times a week in the IRF. The complexity of 
the enrollees medical, rehab, and nursing needs (combined complexity) was not appropriate for acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The enrollees rehab needs could 
be safely provided in an alternate and low intensity setting such as in a skilled nursing facility (SNF) once 
medical issues have cleared. 
 
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 
May 8, 2023, to May 13, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you believe there is an 
issue with how the benefits were applied for the inpatient hospital stays. 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 $250 
copayment per day for days 1-6 and a $0 copayment per day for days 7-90 of each inpatient hospital stay.  
 
You have been asked to pay $919.14, which is less than the standard $250 copayment per day for days 1-5 of 
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 May 8, 2023, to 
May 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 16, 2023, billed with 
evaluation and management code 99223. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the procedure code is inconsistent with the place 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service.  
 
We looked at the file and Medicare rules. This claim was billed with place of service code 23 which is 
inappropriate for code 99223. Based on this information, we decided that Medicare rules for coverage of the 
practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on May 16, 2023, billed with evaluation and management code 99223.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 
87641 and 87500 billed for May 22, 2023. 
 
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 procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500 are 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique. The definition of code 87653 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The definition of code 
87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. The definition of code 87641 is infectious agent detection by nucleic acid (DNA or 
RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87500 is 
infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species 
van A, van B), amplified probe technique. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500 are not supported in the 
medical record. Specifically, a panel was performed and there is a more appropriate singular code for these 
services.. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 
87640, 87653, 87798, 87641 and 87500 billed for May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that the labs were ordered by the treating physician. 
The Plan denied your request. The Plan says an inappropriate place of service was billed. 

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 20, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has no history of 
atherosclerotic cardiovascular disease (ASCVD). Leqvio is indicated as an adjunct to diet and statin therapy for 
the treatment of adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia 
(HeFH), to reduce low-density lipoprotein cholesterol (LDL-C). The records do not support that Leqvio is 
reasonable and medically necessary and safe and effective for the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Leqvio.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeomin. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 may pay for unlabeled uses for FDA-
approved 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Xeomin is not approved by the Food 
and Drug Administration (FDA) for the enrollee's diagnosis. Its use is not supported by one of the major drug 
compendia or clinical research appearing in a Medicare-approved medical journal. Xeomin is therefore not 
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Xeomin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was approved for a left 
reverse total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
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 admission are met in this case. Our 
physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo 
the elective procedure. The procedure is an ambulatory procedure. There is no documentation provided 
indicating medical necessity for inpatient level of care services. The record does not show that at the time of 
inpatient admission it was reasonable for the admitting physician to expect that the enrollee's necessary hospital 
care (including earlier emergency department and/or observation care) will span two midnights with supporting 
documentation of the enrollee's history and comorbidities, signs and symptoms, current medical needs, and risk 
of an adverse event. 
 
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 acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (93005) collection of venous blood by 
venipuncture (36415) troponin, quantitative (84484) and comprehensive metabolic panel (80053) provided 
March 20, 2023. 
 
You asked the Plan to pay for the diagnostic services. You say that this claim was processed at 66%. This claim 
needs to be reprocessed at the correct rate, which is 56%. 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. Your 
contract with the Plan says that there is $500 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies.  
 The item or service you asked the Plan to pay for falls within the Outpatient diagnostic tests and therapeutic 
services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $500 deductible which applies to Outpatient diagnostic tests and therapeutic services and 
supplies. This cost sharing is a contractual obligation that had not been met at the time the diagnostic services 
was received on March 20, 2023. Therefore, we decided that the Plan does not have to pay for the 
electrocardiogram (93005) collection of venous blood by venipuncture (36415) troponin, quantitative (84484) 
and comprehensive metabolic panel (80053) provided March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 1, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 81456 is bundled into payment for code 81456. 
 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 81456 
is a column II code to column I code 81456 with a modifier indicator of 0. The column II code is therefore not 
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 code 81456 billed for date of service February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Horizon carrier screening (81406) provided on April 21, 
2023. 
 
You asked the Plan to pay for the Horizon carrier screening. You say that  the results of this test directly impact 
the clinical decision making and allows the physician and patient to make medical management decisions. The 
Plan denied your request. The Plan says the enrollee is not symptomatic of a genetic disorder for a therapeutic 
decision or treatment plan as required. 
 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 the Horizon carrier screening have 
been met. Specifically, no medical records or literature was provided to support the service at issue. Only lab 
results were submitted. No office or clinical notes were provided to support medical necessity of this service. 
Therefore, we decided that the Plan does not have to pay for the Horizon carrier screening (81406) provided on 
April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 11, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 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 code 81456 billed for date of service January 11, 2023.