Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided January 15, 2023, to January 
17, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that enrollee was medically stable and qualified for 
observation services. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided January 15, 2023, to January 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 09, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied payment. 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 March 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 20, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on March 20, 2023, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the blood glucose test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that you are appealing the denied test 
strips. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve the blood 
glucose test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 8, 
2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF liquid 
biopsy (81455) provided on January 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services provided on October 28, 
2022, to October 31, 2022. 
 
You asked the Plan to pay for the occupational therapy services. You say that you are requesting gap exception 
coverage. 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 occupational therapy 
services provided on October 28, 2022, to October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance. 
 
You asked the Plan to pre-approve a surgical procedure. You say that the enrollee has pain in the left and right 
knee. The Plan denied your request. The Plan says this procedure is experimental. 
 
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 surgical procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found further studies are needed to demonstrate the requested treatment is as safe and 
effective as standard treatments There is no compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested destruction by a neurolytic agent of the genicular nerve branches, 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 a surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service November 
28, 2022.  
 
You asked the Plan to pay for procedure code 76942. You say that the claim was billed correctly and should be 
paid. 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 76942 is 1. The MAI value for this code is 3. You billed 2 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 76942 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76942 billed for date of service November 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on September 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
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, code A4550 returned OCE edit 62 as this code is not allowed under the Outpatient Prospective 
Payment System (OPPS). This edit denies the claim and returns the claim to the provider. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the outpatient services provided on September 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on January 27, 2023, 
to February 3, 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. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
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 diagnosis code E43. 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 use of diagnosis code E43 is not supported by the records provided. Our physician 
reviewer found that the documentation does not consistently and completely support the assigned secondary 
diagnosis code E43, Unspecified severe protein-calorie malnutrition. The decision to remove the secondary 
diagnosis code and adjust the DRG is supported.  
 
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 the inpatient hospital services provided on January 27, 2023, to February 3, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Zilretta injection provided on December 20, 2021. 
 
You asked the Plan to pay for the Zilretta injection. You say that you were advised that the injection was okay 
to give and would be covered. You also say that the claim remains unpaid. The Plan denied your request. The 
Plan says that Zilretta is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Zilretta injection. Our reviewer says that 
the Zilretta injection is medically necessary. Our physician reviewer found repeat administration of Zilretta 
using a flexible dosing schedule timed to patient response was well tolerated, with no radiographic evidence of 
cartilage impact. Both injections resulted in similar improvements in osteoarthritis symptoms across a broad 
spectrum of disease severity reflective of that seen in clinical practice. The reviewer found that the 
documentation supports that the Zilretta is medically reasonable and necessary for the enrollee. The reviewer 
also found that the documentation supports that the Zilretta is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Zilretta injection have been met. Therefore, we decided that the Plan has to 
pay for the Zilretta injection provided on December 20, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service October 25, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service October 25, 2022, billed 
with code 99153.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 
15, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF liquid 
biopsy (81455) provided on January 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing code 81269 billed for date of service August 
8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was necessary for the most accurate 
outcome. The Plan denied your request. The Plan says the test 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 looked at the file, and Medicare rules. Testing billed with code 81269 is automatically denied as not 
medically necessary. 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 lab testing code 81269 billed for date of 
service August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87798, 87801, 87641, and 87500 
billed for date of service April 27, 2022. You asked the Plan to pay for the billed services. You say that medical records were submitted. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes 87150, 87798, 87801, 87641, and 87500 were billed with the -91 modifier. The 
records do not indicate a repeat test was provided on the date of service at issue. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 87150, 87798, 87801, 87641, and 87500 billed for date of 
service April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve block injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee's pain is most pressing with standing 
and ambulating for a long period of time. You say that the enrollee is currently using crutches to help them 
ambulate. The Plan denied your request. The Plan says that the peripheral nerve block injection 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 injection. Our reviewer says that 
peripheral nerve block injection is considered experimental. Our physician reviewer found that the enrollee 
takes hydrocodone which helps with their pain. There are only case reports and small case series which is not 
evidence-based therapy. Therefore, request for a peripheral nerve block injection is considered experimental. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve peripheral nerve block injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has medical needs that 
exceed skilled nursing facility (SNF) capabilities, and you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says  the enrollee does not meet all the requirements for 
admission to the LTACH.  
 
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 all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on January 14, 2023. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the 
ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the requested ambulance services were not medically reasonable and necessary. Our physician reviewer 
found that had a skin tear on the left forearm. The review has determined that prior to transfer the enrollee was 
hemodynamically stable. The documentation did not support that other means of transport (such as stretcher 
van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient on 1/14/23. 
The documentation did not support that the patient needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully-equipped ambulance can provide for safe transport on 1/14/23. The 
documentation did not support that the ambulance transport on 1/14/23 was medically reasonable and 
necessary for the patient.  
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance transportation provided on January 14, 2023.