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

 
We decided that the Plan does not have to pay for the lab services provided on March 01, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were 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 lab services provided 
on March 01, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the thrombolytic therapy (36224, 36226, 61465, 36227) provided on 
February 22, 2023. 
 
You asked the Plan to pay for the thrombolytic therapy. You say that the services should be covered. The Plan 
denied your request. The Plan says that this should be billed to Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not give a reason why this should be billed to Original Medicare.  
Therefore, we decided that the Plan has to pay for the thrombolytic therapy (36224, 36226, 61465, 36227) 
provided on February 22, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 15, 
2023.  
 
You asked the Plan to pay for procedure code 99285. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99285 is bundled into 
payment for code 99223. 
 
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 99285 is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99285 billed for date of service January 15, 2023.
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 for IRF care is medically necessary. The 
Plan denied your request. The Plan says services requested do not meet the requirements for approval. 
 
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 you were admitted for rhabdomyolysis, sepsis and pneumonia. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical 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 you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the alginate dressing (A6196) provided on February 17, 2023. 
 
You asked the Plan to pay for the alginate dressing. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says that that no separate payment can be made for 
billed code A6196. 
 
The Plan must follow Medicare rules. Medicare rules say that if the item or service is covered as incident to a 
physician service and is provided on the same day as a physician service, payment for it is bundled into the 
payment for the physician service to which it is incident. 
 
We looked at the file and Medicare rules. The record shows that no other CPT code was billed on the claim that 
would make A6196 bundled. The alginate dressing is not bundled with a physician service and can be 
reimbursed separately. Therefore, we decided that the Plan has to pay for the alginate dressing (A6196) 
provided on February 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI)-guided transurethral 
ultrasound ablation (TULSA) (55899) provided on December 15, 2022. 
 
You asked the Plan to pay for the services. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the service 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that TULSA is considered experimental or investigational. There is not enough scientific proof to 
support the safety and success of TULSA to use it outside of a clinical trial.  
 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 the magnetic resonance imaging (MRI)-guided transurethral ultrasound ablation (TULSA) 
(55899) provided on December 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. 
 
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 imaging. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation that the electrocardiogram (ECG) shows an uninterpretable pattern or that 
the enrollee is unable to exercise. There is no evidence provided that would support the need for radionuclide 
stress testing at this time. In summary, there is insufficient documentation to support the medical necessity for 
the requested cardiac stress testing in this enrollees clinical management.  
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging (MPI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic facet joint injections. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical necessity of proceeding with ongoing therapeutic medial branch blocks rather than the 
indicated therapy involving RFAs has not been demonstrated. 
 
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 pre-approve therapeutic facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will not be able to get up on their own if 
released. The Plan denied your request. The Plan says the requested IRF services do not meet the requirements 
for approval.  
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous nerve stimulation unit (E0745, A4557, 
A4595) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a transcutaneous nerve stimulation unit. You say that the requested unit is 
the only safe modality the enrollee is able to use at this time for pain relief. The Plan denied your request. The 
Plan says the enrollee must use network providers to get her medical care and services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a transcutaneous nerve stimulation unit (E0745, A4557, A4595) to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on December 29, 2022. 
 
You asked the Plan to pay for the pathology services. You say that the diagnosis codes were billed correctly on 
this claim. The Plan denied your request. The Plan says you billed the incorrect Place of Service for this claim 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill services with the correct 
Place of Service (POS) code.  POS 21 indicates that the service occurred in an inpatient hospital setting.  POS 
22 indicates that the service occurred in an outpatient hospital setting. 
 
In this case, you billed the service in dispute with POS 22.  However, the records show that the services 
occurred during an inpatient hospital stay. As a result, POS 21 should have been billed instead. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay 
for pathology services provided on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99204, 74230, 72040, 70100, 70310, and 
74240 provided on January 25, 2023. 
 
You asked the Plan to pay for procedure codes 99204, 74230, 72040, 70100, 70310, and 74240. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that for mobile units serving an entity with its own POS 
code, the entity's POS code should be reported. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit and imaging services have not been met. The documentation supports that the enrollee was at a skilled nursing facility on the date of service. As such, the use of the office POS code is not 
appropriate. Therefore, we decided that the Plan does not have to pay for procedure codes 99204, 74230, 
72040, 70100, 70310, and 74240 provided on January 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 You asked the Plan to pre-approve Truxima. You say that Truxima is medically necessary. The Plan denied 
your request. The Plan says a trial of Ruxience or Riabni is required first. 
 
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 Truxima. Our reviewer says that 
Truxima is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal test (81479) provided January 10, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you provided the Guardant Reveal molecular 
diagnostic test at the request of the ordering physician The Plan denied your request. The Plan says this test is 
considered investigational and unproven. 
 
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.  Per DEX Diagnostics Exchange Registry, Guardant Reveal is not 
covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant Reveal 
test (81479) provided January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Inpatient hospital Practitioner services provided on August 3, 
2022, billed with evaluation and management (EM) code 99223. 
 
You asked the Plan to pay for the Inpatient hospital 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 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. 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 Inpatient hospital Practitioner services provided. Our 
reviewer says that documentation does not support the billed code. Our reviewer found that the documentation 
does not support medical decision making of high complexity. There is a more specific code for the level of 
care provided. 
 
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 Inpatient hospital Practitioner services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for Inpatient hospital Practitioner services provided 
on August 3, 2022, billed with evaluation and management (EM) code 99223.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95251 provided on January 17, 2023. 
 
You asked the Plan to pay for procedure code 95251. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 95251 is not supported in the record. Specifically, CPT code 95251 is not on the list of 
approved telehealth service CPT codes. Based on this information, we decided that Medicare rules for coverage 
of the ambulatory continuous glucose monitoring have not been met. The billed place of service, in this case 
10, is for a telehealth visit. Therefore, we decided that the Plan does not have to pay for procedure code 95251 
provided on January 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the provided records document that the home ventilator is being requested for use in a volume assured pressure 
support (TTV-VAPS) mode, which is a modality that could be provided by a bilevel positive airway pressure 
(BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. The provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. The provided 
records in this case do not provide adequate detailed information to meet Medicare criteria for coverage of a 
ventilator as opposed to 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (74240, 74230) provided on January 17, 
2023. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is non-covered in the mobile setting.  
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or fluoroscopy are not covered in the mobile setting. 
 
We looked at the file and Medicare rules. This service was performed in a mobile setting and involved the 
administration of Barium and fluoroscopy. Based on this information, we decided that Medicare rules for 
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay 
for radiology services (74240, 74230) provided on January 17, 2023.