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

 
We decided that the Plan has to pay for initial hospital care (procedure code 99223) rendered on December 10, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 99223 remains 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 care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes 
are spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee presented with a left 
humerus fracture and a right great toe wound. She had x-rays, IV pain medication, IV antibiotics, admission 
with podiatry and orthopedics consultations. The documentation supports a comprehensive history and 
examination. There was medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
initial hospital care (procedure code 99223) rendered on December 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing billed with codes G0483 for 
January 12, 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 were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee's diagnosis is the services 
were not medically necessary. The records show presumptive screening test results that are partially 
inconsistent with prescription medications, or history and expected results. The records also show the enrollee 
is taking a medication with abuse potential for which there was no presumptive test commercially available. 
The records do not support that the criteria for coverage are met and that the testing was 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 pay for the definitive drug testing billed with codes G0483 for January 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77067 and 77063 billed for date of service 
February 28, 2023.  
 You asked the Plan to pay for procedure codes 77067 and 77063. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 77067 and 77063 is 1. The MAI value for this code is 2. You billed 2 
units of each of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 77067 and 77063 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 77067 and 77063 billed for date of service February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for nonadjunctive, nonimplanted 
continuous glucose monitor (CGM) and accessories (A4239) and a nonadjunctive, nonimplanted CGM receiver 
(E2103). 
 
You asked the Plan to pre-approve CGM and supplies. You say that you have never been started on insulin and 
you do not have hypoglycemia. You also say that your life is in 
danger for the inability to properly monitor your blood sugar levels. The Plan denied your request. The Plan 
says the records do not show that you use insulin or that you have had hypoglycemia. You do not meet criteria 
for approval of the requested CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia Based on this information, we decided that Medicare rules for coverage 
of CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
supply allowance for nonadjunctive, nonimplanted continuous glucose monitor (CGM) and accessories 
(A4239) and a nonadjunctive, nonimplanted CGM receiver (E2103).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes R0070 and Q0092 billed for date of service 
February 6, 2023. 
 
You asked the Plan to pay for procedure codes R0070 and Q0092. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says procedure codes R0070 and Q0092 are considered 
bundled and not separately payable.  
 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 R0070 and has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code R0070 is not separately payable. Procedure code Q0092 has a status indicator or N and is 
not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure 
codes R0070 and Q0092 have not. Therefore, we decided that the Plan does not have to pay for procedure 
codes R0070 and Q0092 billed for date of service February 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray billed with code 71046 for January 4, 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 codes exclude each other. 
 
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 billed diagnosis codes are not valid because 
they exclude each other. Therefore, we decided that the Plan does not have to pay for the x-ray billed with code 
71046 for January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0239U) provided on January 18, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this service is not supported by the records. 
 
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 genetic testing have been met. No 
clinical records were provided to support this request. The only documentation provided was lab results and 
medical literature. Therefore, we decided that the Plan does not have to pay for genetic testing (0239U) 
provided on January 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee is showing symptoms of AD, and 
the PET scan will help develop a treatment plan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found in this case the enrollee is only suspected 
of having AD. The guidelines do not cover this service unless the enrollee meets diagnostic criteria for both 
AD and FTD. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87631 for date of service December 8, 2022. 
 
You asked the Plan to pay for procedure code 87631. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 87631 is infectious agent detection by nucleic acid (DNA 
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza 
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 3-5 targets. 
 
 
 We find that CPT code 87631 is not supported in the medical record. Specifically, the documentation submitted 
indicates that 15 targets were tested. This is not the most appropriate code to be billed for the services rendered. 
Based on this information, we decided that Medicare rules for coverage of procedure code 87631 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 87631 for date of service 
December 8, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion supplies provided from January 28, 2023, to 
January 30, 2023. 
 
You asked the Plan to pay for the home infusion supplies. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 3, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for home infusion 
supplies provided from January 28, 2023, to January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns on tooth #5, 10, 11, and 12 (D6750). 
 
You asked the Plan to pre-approve the retainer crowns. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says your benefit for the requested items or 
services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on this prior authorization request. 
Therefore, we decided that the Plan does not have to pre-approve retainer crowns on tooth #5, 10, 11, and 12 
(D6750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 3, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 an office visit provided on February 3, 2023, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services in order to return home safely. 
The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the documentation does not support that the enrollee has need for 
complex medical treatment in a LTACH(e.g., multiple and prolonged intravenous therapies, monitoring of 
significantly medically active conditions requiring clinical assessment 6 or more times a day, multiple and 
frequent intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, complex wound care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like 
cardiac monitors, on-site dialysis, or surgical suites). The enrollee does not require services at the LTACH that 
are not available at the acute care hospital or the skilled nursing facility.  The requested treatments are not 
medically necessary at the LTACH level of care. The enrollee has improved medically but still requires 
services in an acute hospital. The enrollee can receive further care at the current acute care hospital or a lower 
level of care when deemed appropriate. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft enhancer (20930). 
 
You asked the Plan to pre-approve a bone graft enhancer. 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 a bone graft enhancer. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is having lumbar spine surgery fusion. Allograft bone graft enhancer is 
not needed. Iliac crest bone graft is the gold standard. 
 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 bone graft enhancer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone graft enhancer (20930).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation. 
 
You asked the Plan to pre-approve lumbar radiofrequency ablation. You say that this is medically necessary. 
The Plan denied your request. The Plan says this request exceeds the frequency limitation for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months. 
 
We looked at the file and Medicare rules. The submitted medical records show that the enrollee has already had 
2 radiofrequency sessions in the past 12 months. Based on this information, we decided that Medicare rules for 
coverage of lumbar radiofrequency ablation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental crowns (D2740, D2751) provided on January 
31, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay more for 
dental crowns (D2740, D2751) provided on January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on February 20, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on February 20, 2023.