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

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service October 3, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these codes are 
included in the facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service October 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abatacept. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee cannot afford the self-injected 
formulation. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Additionally, this drug is primarily considered a self-injectable and wouldnt be approved 
under Part B even if given by a physician. Therefore, we decided that the Plan does not have to pre-approve 
abatacept.  
 
Your complaint about the cost sharing for the medication is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365-59, 96366-59, and 96521 billed for 
March 16, 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 96365-59, 96366-59, and 96521 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 96365-59 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 find that CPT code 96365-59, 96366-59, and 96521 are not supported in the medical record. Specifically, 
the records show that outpatient intravenous insulin treatment (OIVIT) and there is a more appropriate code for 
these services than 96365-59, 96366-59, and 96521. 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 96365-59, 96366-59, and 96521 billed for March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 07, 2023. 
 
You asked the Plan to pay for lab services. You say that you cannot afford to let these claims go unpaid. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
February 07, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on August 11, 2022. 
 
You asked the Plan to pay for the physician service. You say that this should be covered. The Plan denied your 
request. The Plan says that payment for this service has been included in the fee for the procedure. 
 
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 has not substantiated their denial. There is no documentation to show 
that another service was billed and paid. Therefore, we decided that the Plan has to pay for the office visit 
provided on August 11, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on March 02, 2023. 
 
You asked the Plan to pay for injections. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections provided on 
March 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 09, 2023, to March 
02, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on February 09, 2023, to March 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 17, 2023, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81334, 81218, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 17, 2023, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81334, 
81218, and 81272.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on December 20, 2022, to 
December 26, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says that the submitted records do not support 
the billing of diagnosis code R65.21. 
 
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 R65.21 (severe sepsis with septic shock). We asked 
our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally 
billed. Our reviewer says that the submitted records support the billing of diagnosis code R65.21. Our 
physician reviewer found the enrollee presented with confusion and fatigue and a history of stroke. She was 
found to be hypotensive, requiring levophed with urinalysis consistent with a urinary tract infection (UTI) and 
a culture positive for klebsiella. She had a culture-positive infection with shock requiring vasopressor support, 
thus meeting the criteria for the billing of diagnosis code R65.21. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on December 20, 2022, to December 26, 2022, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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 selective catheter placement, arterial system; initial 
second order abdominal, pelvic, or lower extremity artery branch, within a vascular family (36246) and 
selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower 
extremity artery branch, within a vascular family (36247). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the records show that the 
requested procedure is not the standard of care for the enrollee's medical condition. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is the appropriateness and medical necessity of genicular arterial 
embolization in the management of this enrollee's knee pain. While relatively small clinical studies have 
suggested benefit from genicular artery embolization (GAE) in targeting synovial hypervascularity to reduce 
knee pain, literature review indicates a paucity of randomized control trials demonstrating long-term clinical 
benefit. As such, GAE would be considered investigational at this time in the clinical management of 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve selective catheter placement, arterial system; initial second order abdominal, 
pelvic, or lower extremity artery branch, within a vascular family (36246) and selective catheter placement, 
arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within 
a vascular family (36247).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on July 27, 2022, to August 2, 
2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says that the submitted records do not support 
the billing of diagnosis code A41.9. 
 
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 A41.9 (sepsis, unspecified organism). We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. 
Our reviewer says that the submitted records support the billing of diagnosis code A41.9. Our physician 
reviewer found the enrollee presented with altered mental status. She was afebrile with documentation of 
tachycardia. She had slight elevation of white blood cell count at 11.3 and urinalysis consistent with a urinary 
tract infection. She was treated with ceftriaxone. The documentation shows a urinary tract infection with 
systemic inflammatory response syndrome, supporting the billing of diagnosis code A41.9. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on July 27, 2022, to August 2, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that without the ventilator therapy, this enrollee 
is at high risk for hospital readmission and potentially life-threatening exacerbations. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for approval of the requested ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity, 
obesity hypoventilation syndrome, suspected obstructive sleep apnea, and pulmonary hypertension. The body 
mass index (BMI) is 42.5. The enrollee was recently hospitalized and required intubation for acute on chronic 
hypercarbic respiratory failure.  The enrollee was treated with nocturnal bilevel positive airway pressure 
(BiPAP) after extubation but was noncompliant in the hospital. A rapid response was called because the 
enrollee developed changes in mental status off BiPAP, and the enrollee quickly improved on BiPAP. There is 
no diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. This enrollee may benefit from 
BiPAP during sleep as an outpatient. This has not been tried and shown to fail as an outpatient. Medicare does 
not cover a home ventilator for the treatment of obesity hypoventilation syndrome. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 you were independent before and wants that
independence back as soon as possible. The Plan denied your request. The Plan says your records do not show
that you have complex rehabilitation needs that require frequent evaluation by a rehabilitation doctor. Services
needed may be provided safely in a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 for date of service March 22, 2023. 
 
You asked the Plan to pay for procedure code 94761. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with greater than 5 respiratory pathogens 
performed in the Part B outpatient setting are considered not medically reasonable or necessary. 
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue are greater than 5 
pathogen testing. Based on this information, we decided that Medicare rules for coverage of procedure code 
94761 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 94761 
for date of service March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided January 
18, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that kindly find the attached 
documents for review which proves the medical necessity for the billed services and process your claim for 
payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided January 18, 2023.