Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) injection (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the enrollee is unable to take zoledronic acid due to 
severe Gastroesophageal reflux disease (GERD). The Plan denied your request. The Plan says there is no 
indication the member has had an osteoporosis-related fracture. The member has not tried and failed zoledronic 
acid. The Plan also says there is no indication zoledronic acid would likely be less effective or cause adverse 
effects for the member.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
enrollee does not meet the criteria for Prolia. Our physician reviewer found the enrollee has not tried and failed 
the required drug. Our physician reviewer also found there is no documentation indicating that the plans 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (denosumab) injection (J0897).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service July 13, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that an appropriate diagnosis was not billed. 
 
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 medical records show that an FDA-approved Carvykti test was provided. We looked at the file and the 
rules. The claim was billed with diagnosis code C90.00, defined as multiple myeloma not having achieved 
remission. The CMS Transmittal 11774 shows that the billed diagnosis code is indicated for the specific test 
the enrollee received. Based on this information, we decided that the Medicare rules for coverage have been 
met. Therefore, we decided that the Plan has to pay for the lab testing billed for date of service July 13, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on April 4, 2023, billed with 
procedure code 78452. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 78452 is not supported in the medical record. Specifically, the claim was not billed with 
an appropriate diagnosis from the list of approved codes. Based on this information, we decided that Medicare 
rules for coverage of the imaging services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for imaging services provided on April 4, 2023, billed with procedure code 78452.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99050 billed for date of service June 26, 
2023. 
 
You asked the Plan to pay for procedure code 99050. The Plan denied your request. The Plan says procedure 
code 99050 is 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 99050 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99050 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99050 billed for date of service June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services provided on January 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99212) provided from April 7, 2022, to May 
26, 2022. 
 
You asked the Plan to pay for the physician services. You say that you feel the services were processed 
correctly. You also say that you feel you should not have to issue a refund for  The Plan denied your request. 
The Plan says the recoupment is valid. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has sent the bill 
directly to the primary insurer for payment. As the secondary insurer, the Plan cannot be held responsible for 
the physician services until the primary insurer has denied the claim for these services. Therefore, we decided 
that the Plan does not have to pay for the office visits (99212) provided from April 7, 2022, to May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immigration medical exam provided on June 7, 2023. 
 
You asked the Plan to pre-approve an immigration medical exam. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the Plan does not cover 
exams needed for immigration purposes as it is not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that immigration medical exam is not part of the 
routine physical checkup.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an immigration medical exam have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an immigration medical exam provided on June 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87799, 87563, 87640, 87653, 
87798, 87641, and 87500 billed for date of service August 11, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the codes are approved by Medicare. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. The 
documentation supports that this panel used the nucleic acid probe technique. There is no evidence that 
multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a single code 
with one unit of service should be used. Based on this information, we decided that Medicare rules for 
coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87481, 87491, 87799, 87563, 87640, 87653, 87798, 87641, and 87500 billed for date of 
service August 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine services provided on 
September 05, 2023. 
 
You asked the Plan to waive the copayment for the nuclear medicine services. You say that the services should 
be covered. 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 $475 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $475 copayment for the nuclear medicine services. This item/service falls within 
the Outpatient diagnostic tests and therapeutic services and supplies 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 nuclear medicine services provided on September 05, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 84439, 83036, and 84443. 
We decided that the Plan does not have to pay for the services described by procedure code 82306.  
 
You asked the Plan to pay for the lab testing billed for date of service July 6, 2023. You say that physicians 
send specimens for testing. The Plan says that an incorrect place of service was billed. 
 
We decided that the Plan has to pay for the services described by procedure codes 84439, 83036, and 
84443.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 84439, 83036, and 84443 billed 
for date of service July 6, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 82306. 
 
 
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. This 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 have not been met. Therefore, we decided that the Plan does not have to pay for 
the services described by procedure code 82306 billed for date of service July 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 96413 billed for date of service August 28, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the denial is incorrect. The Plan denied your 
request. The Plan says the billed code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. 
 
We find that CPT code 96413 was billed with code J1602, Simponi Aria. The administration of golimumab 
(Simponi Aria) should not be billed using a chemotherapy administration code. Based on this information, we 
decided that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 96413 billed for date of service August 28, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Padcev (J9177). 
 
You asked the Plan to pre-approve Padcev. You say that you believe starting treatment with pembrolizumab 
and Padcev is urgent and in the patient's best interest. The Plan denied your request. The Plan says that the use 
of this drug/regimen is not reasonable and necessary. 
 
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 to pre-approve Padcev. Our reviewer says that the 
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 
for this patient. Our physician reviewer found the requested use of Padcev (J9177) is FDA-approved for the 
enrollees diagnosis. The FDA approval is for the treatment (in combination with pembrolizumab) of locally 
advanced or metastatic urothelial cancer in adults who are not eligible for cisplatin-containing chemotherapy. 
Our reviewer also found that given the patient's multiple comorbidities at this time, they would be a poor 
candidate for cisplatin-based treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Padcev have been met. Therefore, we decided that the Plan has to pre-approve 
Padcev (J9177).  
 
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 procedure code G0482 provided on May 22, 2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the billed code is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
at least 15 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
the billed service have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code G0482 provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203 billed for date of service December 3, 
2022. 
 You asked the Plan to pay for procedure code 99203. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 99203 is bundled into payment for 
codes 97813 and 97814. 
 
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 99203 
is a column II code to column I codes 97813 and 97814. This claim has not been billed with an appropriate 
modifier to bypass the edits. 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 99203 billed for date of service 
December 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service July 31, 
2023.  You asked the Plan to pay for procedure code 88341. You say that medical records were provided. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. The medical records do not provide a rational as to why additional units were 
necessary to treat this enrollee. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88341 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88341 billed for date of service July 31, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90832) provided on June 15, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the record does not include documentation of a consultation or an attempt to 
consult the enrollee's primary/attending physician.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832) provided on June 15, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on February 11, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for procedure code 99285. Our reviewer says that the medical 
records do not support the billing of code 99285. Our reviewer found the enrollee presented to the emergency 
room with generalized weakness, intermittent leg cramps, headaches, blood pressure fluctuations, and nausea. 
At issue is the accuracy of billing code 99285. Medical exam and history are medically appropriate; 
documentation does not support high-level decision-making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on February 11, 2023.