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

 
We decided that the Plan does not have to pay for practitioner services provided on January 29, 2023, to 
January 31, 2023, billed with procedure code 99232. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says that the requested documentation has not been 
provided. 
 
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 practitioner services provided have 
been met. Specifically, no medical records for the dates of service in question have been provided for review. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided on January 29, 
2023, to January 31, 2023, billed with procedure code 99232.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided on November 25, 2021 to December 24, 
2021. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that the provided records do not support the diagnosis code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 home health services. Our reviewer says that the records 
support the billed service. Our reviewer found the attached addendum specifically cites hypertension with 
diastolic heart failure, so the records do support the original diagnosis 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 the home health services have been met. Therefore, we decided that the Plan has 
to pay for home health services provided on November 25, 2021 to December 24, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve 3 doses of Kimyrsa. 
 
You asked the Plan to pre-approve 3 doses of Kimyrsa. You say that if the dosage is not infused the enrollee 
will get admitted to the hospital. The Plan denied your request. The Plan says that Kimyrsa is 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 3 doses of Kimyrsa. Our reviewer says 
that 3 doses of Kimyrsa is medically necessary. Our physician reviewer found that the requested use of 
Kimyrsa is FDA-approved for the enrollee's diagnoses. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 doses of Kimyrsa have been met. Therefore, we decided that the Plan has to 
pre-approve 3 doses of Kimyrsa.  
 
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 provide reimbursement for the transport chair purchased on April 18, 
2023. 
 
You asked the Plan to provide reimbursement for the transport chair. You say that there was no supplier who 
offered the lightweight transport chair you needed. The Plan denied your request. The Plan says this supplier is 
not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to provide reimbursement for the transport chair 
purchased on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A4657 and Q4801 related to end-stage renal disease 
(ESRD) provided on February 3, 2023, to February 27, 2023. 
 
You asked the Plan to pay for codes A4657 and Q4801. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says Medicare does not separately pay for certain ESRD-related 
supplies/drugs. 
 
 The Plan must follow Medicare rules. Medicare rules state certain ESRD related services are not separately 
payable. A4657 is a durable medical equipment (DME) ESRD supply that is not payable to DME suppliers. 
Code Q4081 is a drug that is subject to ESRD consolidated billing. Therefore, we decided that the Plan does 
not have to pay for codes A4657 and Q4801 related to end-stage renal disease (ESRD) provided on February 3, 
2023, to February 27, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76937 and 36000 billed for May 7, 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 the services are not covered. 
 
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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure). 
 
We find that CPT code 76937 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met.  
 
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 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. 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 76937 and 36000 billed for May 
7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DCISion testing rendered on May 15, 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 the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that immunohistochemistry (IHC) stains are not 
medically necessary for breast cancer. 
 
We looked at the file and Medicare rules. The testing at issue is an IHC stain for breast cancer. This testing is not considered medically necessary by Medicare. Therefore, we decided that the Plan does not have to pay for 
the DCISion testing rendered on May 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the upper 
extremity (73221), the cervical spine (72141) and the lumbar spine (72148) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an MRI of the upper extremity, the cervical spine and the lumbar spine to be 
provided by an out-of-network provider. You say that you are claustrophobic and need an open MRI. The Plan 
denied your request. The Plan says the facility chosen is not in network with your health plan. 
 
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 
magnetic resonance imaging (MRI) of the upper extremity (73221), the cervical spine (72141) and the lumbar 
spine (72148) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
October 5, 2022. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for a urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. 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 the 
urine polymerase chain reaction (PCR) panel rendered on October 5, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve Aranesp. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Procrit or Retacrit is required before alternatives can be considered. 
 
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 Aranesp. Our reviewer says that 
Aranesp is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdualag. 
 
You asked the Plan to pre-approve Opdualag. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 Opdualag Opdualag. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the drug/regimen is not being prescribed 
for a supported medically-accepted indication. The requested use of Opdualag FDA-approved for the enrollee's 
diagnosis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdualag have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdualag.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total ankle replacement surgery to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the surgery. You say that the enrollee's primary insurance allows for surgery 
to be completed at this facility. The Plan denied your request. The Plan says there are network providers 
available to provide this service. 
 
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 confirmed there are 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 the total ankle replacement surgery to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization (36246, 36247). 
 
You asked the Plan to pre-approve geniculate artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve geniculate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided medical records and review of the current peer-reviewed medical 
literature do not document that geniculate artery embolization has been shown in controlled studies in a CMS-
approved journal to result in long term health benefits in patients with osteoarthritis of the knee.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of geniculate artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve geniculate artery embolization (36246, 36247).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a periodic comprehensive preventive medicine exam (code 99397) 
provided on May 6, 2023. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine exam. You say that the services 
were medically necessary. The Plan denied your request. The Plan says that you have exceeded the benefit 
limit. 
 
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 not provided a Plan rule or a Medicare rule to 
substantiate their denial. In fact, the Plan based their decision on a Plan rule for an Annual Wellness Visit. 
Therefore, we decided that the Plan has to pay for a periodic comprehensive preventive medicine exam  
(code 99397) provided on May 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for date of service December 
14, 2022. 
 You asked the Plan to pay for procedure code 99215. You say that this service should be paid separately. The 
Plan denied your request. The Plan says payment for code 99215 is bundled into payment for code 99205. 
 
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 99215 
is a column II code to column I code 99205. 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 99215 billed for date of service December 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Levocarnitine and Cyanocobalamin injections for 
electrostimulation therapy rendered on May 4, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of this request has not been demonstrated in the 
peer-reviewed literature. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical value and effectiveness of electrical cell stimulation with injection of levocarnitine and 
cyanocobalamin in the setting of neuropathy/lumbar radiculopathy has not been demonstrated in the peer-
reviewed literature. The review has determined that the requested therapy is not medically reasonable or 
necessary 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for Levocarnitine and Cyanocobalamin injections for electrostimulation therapy rendered on May 
4, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services billed with code 97112 for 
January 20, 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 the billed diagnosis code is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 the physical therapy 
services billed with code 97112 for January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Levocarnitine and Cyanocobalamin Injections for 
electrostimulation therapy and vasopneumatic device therapy rendered on April 24, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of this request has not been demonstrated in the 
peer-reviewed literature. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that these injections and the vasopneumatic therapy are considered experimental. There is not enough 
evidence to support their effectiveness; therefore, the procedure was not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for Levocarnitine and Cyanocobalamin Injections for electrostimulation therapy and 
vasopneumatic device therapy rendered on April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig/cranial prosthesis. 
 
You asked the Plan to pre-approve these services. You say that the correct name for the request is a cranial 
prosthesis. The Plan denied your request. The Plan says the item is not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig/cranial 
prosthesis.