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

 
We decided that the Plan does not have to pre-approve destruction of nerves in the hip joint using heat.  
 
You asked the Plan to pre-approve destruction of nerves in the hip joint using heat. You say that destruction of 
nerves in the hip joint using heat is medically necessary. The Plan denied your request. The Plan says 
destruction of nerves in the hip joint using heat is not medically necessary. The Plan says this type of pain 
procedure is not tested enough or does not have enough positive results to be considered good treatment at this 
time. 
 
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 destruction of nerves in the hip joint 
using heat. Our reviewer says that the requested destruction of nerves in the hip joint using heat is not 
considered medically reasonable and necessary. Our physician reviewer found this procedure is considered experimental/investigational therapy. The efficacy of this procedure varies widely as reported in the peer 
reviewed literature. Therefore, the request is deemed not 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 destruction of nerves in the hip joint using heat have not been met. Therefore, 
we decided that the Plan does not have to pre-approve destruction of nerves in the hip joint using heat.
Appeal type: Lab
Decision: Partially Favorable

 
You asked the Plan to pay for lab codes 87801, 87150-XU, 87481-XU, 87641-XU, 87653-XU, 87798-XU 
provided on March 1, 2023.. You say that you are appealing with supporting records. The Plan says that code 
87801 is not supported by the records. The Plan also says that codes 87150, 87481, 87641,87653, and 87798 
are in code 87801 so are not separately paid. 
 
We decided that the Plan has to pay for 87801.  
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We asked our coding 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 87801, 87150-XU, 87481-XU, 87641-XU, 
87653-XU, 87798-XU. Our reviewer says that code 87801 meets criteria for payment. Our coding reviewer 
found the medical record includes documentation of the testing billed with code 87801; therefore, this 
procedure code should be covered.  
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87801, 87150-XU, 87481-XU, 87641-XU, 87653-XU, 87798-XU have been 
met. Therefore, we decided that the Plan has to pay for 87801.  
 
We also decided that the Plan does not have to pay for 87150-XU, 87481-XU, 87641-XU, 87653-XU, 
87798-XU. 
 
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 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 codes 87150-XU, 87481-XU, 87641-XU, 87653-XU, and 
87798-XU. Our reviewer says that these codes do not meet criteria for separate payment. Our reviewer found 
these codes were appended with modifier -XU indicating unusual non-overlapping services to bypass the NCCI 
edit. However, the laboratory report does not include documentation to support these procedures codes with the 
modifier used. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87150-XU, 87481-XU, 87641-XU, 87653-XU, 87798-XU have not been met. 
Therefore, we decided that the Plan does not have to pay for 87150-XU, 87481-XU, 87641-XU, 87653-XU, 
87798-XU. 
 
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 testing (U0003, U0005) provided on January 
12, 2022. 
 
You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says this testing is 
not covered by the Plan when provided during a skilled nursing facility (SNF) stay. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services provided to a skilled nursing 
facility (SNF) inpatient under Part A are billed by the SNF.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory testing (U0003, U0005) provided on January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission an acute rehabilitation will benefit you to 
returning to being independent again. The Plan denied your request. The Plan says the enrollee's records do not 
show the need for an intensive team for care. The Plan says that the services needed may be provided safely in 
a lower level of care.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 October 13, 2020. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5213).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87481, 87500, 87653 and 
87798 provided November 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are attaching detailed medical records 
which prove that the services billed were medically necessary.  The Plan denied your request. The Plan says the 
documentation does not support the billed service. 
 
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 87481 is infectious agent detection by nucleic acid (DNA 
(deoxyribonucleic acid) or RNA (ribonucleic acid)); candida species, amplified probe technique, 87500 is 
infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species 
van A, van B), amplified probe technique, 87653 is infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique and 87798 is infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified. 
 
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 laboratory services. Our reviewer says that the requested 
items/services are not supported in the documents in this case.  Our reviewer found the medical record includes 
a physician order for a urinary tract infection (UTI) Panel, and evaluation and management procedure with 
urine dip stick testing and radiology service. Therefore, these procedures cannot be verified as performed. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 87481, 87500, 87653 and 87798 provided November 
19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 9 units of code B4185 provided on April 8, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed units are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 services Our reviewer says that 9 units of 
code B4185 is not supported by the records provided. Our physician reviewer found that the medical record 
does not support 9 units of service billed. For lipids, one unit of service of code B4185 is billed for each 10 
grams of lipids provided; 500 ml of 10% lipids contains 50 grams of lipids (5 units of service); 500 ml of 20% 
lipids contains 100 grams (10 units of service); 500 ml of 30% lipids contains 150 grams (15 units of service). 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for 9 units of code B4185 provided on April 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented ongoing home health physical therapy needs. The enrollee is consistently 
ambulating more than 100 feet and functioning at a level commiserate with a lower level of function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (G0151).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that this item is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pre-approve a MyoPro orthosis. Our reviewer says 
that the requested item is considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee's medical records supports the need for this item. 
 
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 MyoPro orthosis have been met. Therefore, we decided that the Plan has to 
pre-approve a MyoPro orthosis (L8702).  
 
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 assistant surgery services (29876, 29880) provided on 
February 16, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon 
services are not payable. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 29880. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure.  
 
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 services. Our reviewer says that the 
assistant surgery services are not medically reasonable and necessary. Our physician reviewer found that peer-
reviewed literature notes this procedure can be performed without an assistant. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 29880 have not been met. 
 
Medicare rules also state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are 
not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 
29876. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for code 29876 have not been met. Therefore, 
we decided that the Plan does not have to pay for the assistant surgery services (29876, 29880) provided on 
February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80048, 80053, 80202, 82140, 82375, 82805, 
83050, 83735, 84100, 85018, 85027 and 85730 billed for dates of service from December 21, 2022, to 
December 23, 2022. 
 
You asked the Plan to pay for procedure codes 80048, 80053, 80202, 82140, 82375, 82805, 83050, 83735, 
84100, 85018, 85027 and 85730. You say that you have billed the services at issue correctly. The Plan denied 
your request. The Plan says payment for code 85018 is bundled into payment for code 85027. The Plan says 
that the remaining codes have been incorrectly billed with a modifier indicating a professional component. 
 
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 85018 is a column II code to column I code 85027. 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. 
 
We have also confirmed that the remaining codes have a professional/technical component flag of 9. The codes 
at issue have been inappropriately billed with modifier 26 to indicate the professional component of the 
services at issue. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 80048, 80053, 80202, 82140, 
82375, 82805, 83050, 83735, 84100, 85018, 85027 and 85730 billed for dates of service from December 21, 
2022, to December 23, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that this is necessary for treatment of the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Ferrlecit and Venofer. 
 
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 Injectafer. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Ferrlecit and Venofer. The reviewer also 
found that there is no documentation provided indicating that the Plan's required drugs would likely be less 
effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy 
criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service April 25, 2023. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the level of care billed. 
The Plan denied your request. The Plan says 99285 is not supported because the presenting problem was not a 
high/immediate threat to life. This service was appropriately down-coded to 99284. 
 
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 these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 
 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the patient had a history of chronic obstructive pulmonary 
disease (COPD) and presented to the emergency room with several weeks of symptoms. They were ruled out 
for acute coronary syndrome and h was discharged with 4 days of prednisone for COPD. The documentation 
supports a comprehensive exam, but not a comprehensive history or medical decision making of high 
complexity. The records do not support the presenting problems were of high severity, posing an immediate 
threat to life and function. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit on March 02, 2023. 
 
You asked the Plan to waive the cost share for an office visit. You say that you never received a bill more than 
$15. 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 10% 
coinsurance of the approved amount. The annual deductible applies for provider services. Coverage includes, 
but is not limited to consultation, diagnosis, and treatment by a specialist. The provier billed in the amount of 
$205 and the allowed amount is $131.14. Therefore, results in the total cost sharing amount of $131.14. 
 
You have been asked to pay a $131.14 cost share for an office visit. This item/service falls within the doctor 
and other health care provider 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 cost share 
for an office visit on March 02, 2023.