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

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on August 7, 2023. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the PCR testing is considered unproven and 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 urine PCR panel testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this degree of testing was 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 urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on August 7, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 22, 2023, to March 
23, 2023, billed with procedure codes 99223, 99233, and 93880-26. 
 
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 codes. 
 
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 codes 99223, 99233, and 93880-26 is initial hospital inpatient 
or observation care, per day, for the evaluation and management of a patient, which requires a medically 
appropriate history and/or examination and high level of medical decision making. When using total time on 
the date of the encounter for code selection, 75 minutes must be met or exceeded, subsequent hospital inpatient 
or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on 
the date of the encounter for code selection, 50 minutes must be met or exceeded, and duplex scan of 
extracranial arteries; complete bilateral study. 
 
We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found documentation does not support the 
duplex scan of extracranial arteries, complete (93880-26) was completed on this date range, only that a carotid 
artery ultrasound was performed. Also, the notes included appropriate histories and exams, but did not support 
a high level of medical decision making or encounter duration of 50 or 75+ minutes, respectively to support the 
codes, 99223 and 99233 for these dates.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 22, 2023, to March 23, 2023, billed 
with procedure codes 99223, 99233, and 93880-26.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 05, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail biopsy polymerase chain reaction (PCR) testing 
provided on August 24, 2022. 
 
You asked the Plan to pay for the nail biopsy PCR testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says experimental services are not covered. 
 
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 nail biopsy PCR testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the longstanding standard of care for the evaluation of fungus in toenails is the 
performance of both KOH and fungal culture on a toenail specimen. These laboratory tests are inexpensive, 
sensitive, and specific. It is unclear as to why this enrollees toenail required PCR testing as compared to KOH 
and fungal culture. Therefore, the PCR testing of this enrollees toenail was 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 nail biopsy PCR testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the nail biopsy polymerase chain reaction (PCR) testing provided on August 24, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on February 7, 2023, to February 
11, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the DRG billed. The Plan denied your request. The Plan says that the submitted 
medical record does not contain sufficient documentation to clinically validate the secondary diagnoses of 
J96.21 (Acute and chronic respiratory failure with hypoxia) and J96.22 (Acute and chronic respiratory failure 
with hypercapnia). As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnoses of J96.21 (Acute and chronic 
respiratory failure with hypoxia) and J96.22 (Acute and chronic respiratory failure with hypercapnia). We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that the secondary diagnoses of J96.21 (Acute and chronic respiratory 
failure with hypoxia) and J96.22 (Acute and chronic respiratory failure with hypercapnia) are supported by the 
medical record. Our physician reviewer found this patient presented with respiratory failure, with chronic 
obstructive pulmonary disease exacerbation, and documented hypoxia and hypercapnia on arterial blood gas. 
Therefore, the patient met criteria for the secondary diagnoses at issue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on February 7, 2023, to February 11, 2023, at the Diagnosis Related Group (DRG) 
originally billed.   
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T).   
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is 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 pre-approve this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provider is requesting the injection of VIA Disc into the spinal disc for advanced degenerative 
disc disease against the Food and Drug Administration (FDA) approval guidelines.   
 
 
 
Large well-designed studies in the peer review scientific literature comparing stand-alone use of VIA Disc to 
established treatments are needed. Published studies do not demonstrate any long-term health outcome 
advantage with the use of VIA Disc NP as an alternative to standard treatments. The review has determined 
that the service at issue in this case 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral 
disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve sedation for bilateral radiofrequency ablation. 
 
You asked the Plan to pre-approve sedation for bilateral radiofrequency ablation. You say that sedation for 
bilateral radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says that 
sedation for bilateral radiofrequency ablation does not meet the Medicare guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that sedation for bilateral radiofrequency ablation is 
covered when the criteria listed in the Medicare rules section of this decision 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 pre-approve sedation for bilateral radiofrequency 
ablation. Our reviewer says that sedation for bilateral radiofrequency ablation is considered medically 
reasonable and necessary in this case. Our physician reviewer found the patient with poor hypertension and 
weighs 222 pounds. Radiofrequency ablation requires the patient remain still while in the prone position and in 
obese patients this can be very challenging. Similarly, blood pressure control is very important during this 
procedure. The request is 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 sedation for bilateral radiofrequency ablation have been met. Therefore, we 
decided that the Plan has to pre-approve sedation for bilateral radiofrequency ablation.  
 
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 practitioner services provided on April 9, 2023, to April 14, 
2023, billed with evaluation and management (EM) codes 99223 and 99233 (x4). 
 
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 codes. 
 
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 codes 99223 and 99233 is initial hospital inpatient or 
observation care, per day, for the evaluation and management of a patient, which requires a medically 
appropriate history and/or examination and high level of medical decision making. When using total time on 
the date of the encounter for code selection, 75 minutes must be met or exceeded, and subsequent hospital 
inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the documentation provided does not 
notate that the enrollee was admitted to the hospital which would support the 99223, and since there is no 
documentation of admission, documentation does not support 99233. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 9, 2023, to April 14, 2023, billed with 
evaluation and management (EM) codes 99223 and 99233 (x4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 24, 2022, to 
August 29, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 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 providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code I21.A1, described as 
myocardial infarction type 2. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found that the documentation described the enrollee presenting with shortness of 
breath and elevated blood pressure. He was diagnosed with acute heart failure and hypertensive urgency. He 
was given Lasix. Troponin T levels were 118, 110, and 106, down trending. Electrocardiogram (ECG) showed 
evidence of atrial fibrillation with normal rate. No STEMI was noted. The enrollee did not report any chest 
pain or other cardiac symptoms. As such, code I21.A1 is not sufficiently supported for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 24, 2022, to August 29, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power wheelchair accessory (E2310) provided on April 28, 
2023. 
 
You asked the Plan to pay for the item. You say that this should be paid for. The Plan denied your request. The 
Plan says Healthcare Common Procedure Coding System (HCPCS) code E2310-NU-BP-KX (1 units) 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 Healthcare Common Procedure Coding System (HCPCS) code 
E2310 is "Power wheelchair accessory, electronic connection between wheelchair controller and one power 
seating system motor, including all related electronics, indicator feature, mechanical function selection switch, 
and fixed mounting hardware."  
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 item. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that E2310 is not supported. The record 
states that the product supplied does not meet the description of this code; there is a more specific code to 
report the product in question. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pay for a power wheelchair accessory (E2310) provided on April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on May 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81455) provided on May 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vagus nerve stimulation (VNS) services (61885). 
 
You asked the Plan to pre-approve VNS services. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested services are 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 pre-approve VNS services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records do not document that the enrollee in this case has medically refractory 
partial onset seizures for whom surgery is not recommended or for whom surgery has failed, or that the 
enrollee has treatment-resistant depression. In addition, the provided medical records and review of the current 
peer-reviewed medical literature do not document that use of the VNS has been shown in controlled studies in 
a Medicare-approved journal to result in long-term health benefits in patients with hemiplegia and hemiparesis 
following cerebral infarction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VNS services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vagus nerve stimulation (VNS) services (61885).
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital 
currently because of evidence with active bleeding in colostomy and definitive management of intra-abdominal 
infection is still being determined by infectious disease and interventional radiology.  
 
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 current acute care setting as provided by 
the Plan.  
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.