Persius/hicric huggingface dataset:
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 a lower level of care is not safe, sufficient, or 
equipped to address the enrollee's needs related to their comorbidities and will place them at a higher risk for 
further decompensation. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an IRF.  
 
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 the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement (36215), non-selective catheter 
placement (36221) and angiography (75710 and 75716) provided on January 18, 2023. 
  You asked the Plan to pay for selective catheter placement (36215), non-selective catheter placement (36221), 
angiography (75710 and 75716). You say that the documentation should be reviewed. The Plan denied your 
request. The Plan says procedure codes 36215 and 36221 are not supported by the medical records submitted. 
The Plan also says that procedure codes 75710 and 75716 are considered inclusive to procedure code 37246. 
 
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 codes 75710 and 75716 are column II codes to column I code 37246; 
however, 75710 and 75716 were billed with a modifier.  
 
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 selective catheter placement (36215), non-selective catheter 
placement (36221), angiography (75710 and 75716). Our reviewer says that the documentation was reviewed 
and does not meet the criteria for coverage. Our reviewer found the procedure report describes an intervention 
performed, which includes radiological interpretation. Therefore, procedure codes 75710 and 75716 denied 
correctly as they were unbundled from the angioplasty. In addition, the operative report does not include 
sufficient documentation to confirm the selective catheter placement has been performed. The operative report 
also does not include documentation to support diagnostic studies of the cervicocerebral arteries. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective catheter placement (36215), non-selective catheter placement (36221), 
angiography (75710 and 75716) have not been met. Therefore, we decided that the Plan does not have to pay 
for selective catheter placement (36215), non-selective catheter placement (36221) and angiography (75710 
and 75716) provided on January 18, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2023 to March 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2023 to March 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart cardiac contractility modulation 
system (CCM) (0408T). 
 
You asked the Plan to pre-approve the Optimizer Smart CCM. You say that the enrollee's provider advised they 
are not a indicated for any other approved therapy at this time. The Plan denied your request. The Plan says this 
device is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Optimizer Smart CCM. Our 
reviewer says that the requested Optimizer Smart CCM is not considered medically reasonable and necessary 
in this case. Our physician reviewer found this device is considered investigational as additional research is 
needed. Therefore, the reviewer found that the the requested device is not medically reasonable or 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 Optimizer Smart CCM have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer Smart cardiac contractility modulation system (CCM) (0408T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 27, 2023. 
 
You asked the Plan to pay for lab tests. You say that there is no contractual agreement which indicates these 
tests should be included in the dialysis rate. The Plan denied your request. The Plan says this lab testing is 
included in the prospective payment system (PPS) payment made to the dialysis facility and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services furnished for the treatment of ESRD 
are included in the ESRD PPS and are not separately paid.  
 
We looked at the file and Medicare rules. Payment for this testing is included in the ESRD PPS payment and 
these tests are not separately payable. Based on this information, we decided that Medicare rules for coverage 
of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on January 
2, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on January 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service November 
1, 2022. 
 
You asked the Plan to pay for procedure code(s) 88305. You say that you disagree with the denial. The Plan 
denied your request. The Plan says this code is included in the skilled nursing facility payment and is 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 SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 88305 has a Professional/Technical indicator of 1. This means that CPT code 88305 has 
both a professional and technical component. In this case, CPT code 88305 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 88305 billed for date of service November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravascular shockwave lithotripsy (ISL) (0715T) 
provided on February 6, 2023. 
 
You asked the Plan to pay for the ISL. You say that this service was necessary to complete as part of the staged 
percutaneous coronary intervention (PCI) procedure. The Plan denied your request. The Plan says the service 
was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ISL. Our reviewer says that the ISL is not considered medically reasonable and necessary in this case. Our physician reviewer found ISL for is 
considered investigational in the treatment of the enrollee's condition. Additional research is needed. Therefore, 
the reviewer found that the ISL procedure is not 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 the ISL have not been met. Therefore, we decided that the Plan does not have to 
pay for the intravascular shockwave lithotripsy (ISL) (0715T) provided on February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the device is medically necessary. 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to obesity hypoventilation syndrome. Provided records document that 
the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed with code G0483 for September 26, 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing billed with code G0483 for September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service April 12, 
2023.  You asked the Plan to pay for procedure code 88374. You say that these services were necessary and are 
supported in the medical record. 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 88374 is 5. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on February 24, 2023, billed 
with code 99204. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 have been provided for review. Therefore, we decided that the Plan 
does not have to pay for Practitioner services provided on February 24, 2023, billed with code 99204.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750 x 6) for tooth number's 7, 12, 13, 27, 28, 
29. 
 
You asked the Plan to pre-approve the dental services. You say that you have not used your dental benefit for 
crowns yet. The Plan denied your request. The Plan says your benefit for the requested item or service 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 item or service was exhausted on date of service December 20, 2022. 
Therefore, we decided that the Plan does not have to pre-approve crowns (D2750 x 6) for tooth number's 7, 12, 
13, 27, 28, 29.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy. 
 
You asked the Plan to pre-approve Yervoy. You say that the requested drug, Yervoy, is needed. The Plan 
denied your request. The Plan says this type of treatment is not considered appropriate for the member's 
condition, nor does it comply with the criteria set forth by CMS. 
 
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 Yervoy. Our reviewer says that the 
elements of coverage criteria for the requested drug, Yervoy, are not satisfied. Our physician reviewer found 
the FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved 
cancer drug compendia do not contain sufficiently supportive citation for the use of the requested drug as 
prescribed in the enrollee's clinical situation. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Yervoy.
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have not been met. 
 
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 the enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83145 billed for date of service October 24, 
2022. 
 You asked the Plan to pay for procedure code 83145. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 83145 is bundled into payment for code 0089U. 
 
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 83145 
is a column II code to column I code 0089U. 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 83145 billed for date of service October 24, 
2022.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost share for the drug injection and drug administration provided 
on March 11, 2023. We also decided that the Plan does not have to waive the coinsurance for the drug 
injections and drug administration provided on March 12, 2023, and March 13, 2023.  
 
You asked the Plan to waive the cost share for the drug injections and drug administration. You say that you 
believe all COVID-19 treatment must be paid in full. The Plan denied your request. The Plan says that this cost 
sharing was charged correctly. 
 
We decided that the Plan has to reduce the cost share for the drug injection and drug administration 
provided on March 11, 2023.  
 
The Plan says that you must pay $338.13 for the Part B drug. Based on the Plan contract, however, you cannot 
be asked to pay more than 20% coinsurance. The Plan also says you must pay $56.25 for the drug 
administration. The Plan contract says that you cannot pay more than a $50 copayment for specialist services, 
including drug administrations. Therefore, we decided that the Plan has to reduce the cost share for the drug 
injection and drug administration provided on March 11, 2023.  
 
We also decided that the Plan does not have to waive the coinsurance for the drug injections and drug 
administration provided on March 12, 2023, and March 13, 2023. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Medicare Part B drugs. Your contract with the Plan also clearly says that you must 
pay a $50 copayment for each in-network specialist service. 
 
You have been asked to pay 20% coinsurance for each drug injection provided on March 12, 2023, and March 
13, 2023. This item/service falls within the Medicare Part B drugs benefit category. You have also been asked 
to pay up to a $50 copayment for each drug administration service. This item/service falls within the 
physician/practitioner services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the drug injections and drug administration provided on March 12, 2023, and March 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.