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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 5, 2022, to July 
7, 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 J96.01, described as acute 
respiratory failure with hypoxia. 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 the enrollee presented with shortness of breath and fatigue. She was found 
to have pneumonia, a chronic obstructive pulmonary disease (COPD) exacerbation and rapid rate atrial 
fibrillation. These diagnoses easily account for her signs and symptoms. There is no evidence of respiratory 
failure or a need for respiratory/ventilatory support. As such, the billing of J96.01 is not 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 inpatient hospital services provided on July 5, 2022, to July 7, 2022, at the Diagnosis Related Group (DRG) 
originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 8, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says when the 
Plan receives the primary insurer's explanation of benefits, the Plan will process this claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan 
cannot be held responsible for the physician's services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for physician's services provided on 
November 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT) (77373). 
 
You asked the Plan to pre-approve SBRT. You say that the enrollee needs the requested treatment because of 
his inability to lie down comfortably due to the pain, the spine tumor, is causing him. The Plan denied your 
request. The Plan says that Medicare does not cover unproven and not medically necessary procedures. There 
is no good evidence SBRT is best for your cancer. 
 
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. A request for information was sent to the Plan requesting medical records and 
the medical records were not provided. Therefore, we decided that the Plan has to pre-approve stereotactic 
body radiation therapy (SBRT) (77373).  
 
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 anesthesia for diagnostic or therapeutic nerve blocks and 
injections (01992) provided April 9, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that this enrollee had a lumbar injection 
performed by the doctor who requires that the enrollee receive anesthesia care for the safety and comfort of the 
enrollee during the procedure. The Plan denied your request. The Plan says this service does not meet the 
coverage requirements. 
 
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 anesthesia services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a history of chronic obstructive pulmonary 
disease, coronary artery disease, and hypertension. The enrollee is undergoing epidural steroid injections for 
back pain related to degenerative disc disease.  Peripheral nerve blocks may be used for both diagnostic and 
therapeutic purposes. Diagnostically, a peripheral nerve block allows the clinician to isolate the specific cause 
of pain in an individual patient. The injection of local anesthetic, with or without steroid may also provide an 
extended therapeutic benefit. If the patient does not achieve sustained relief a denervation procedure via 
chemical, cryoneurolysis or radiofrequency may be effective at providing long term relief. Epidural steroid 
injection may be completed with only topical local anesthesia or under intravenous (IV) sedation. There is no 
specific clinical rationale for the use of anesthesia for the procedure. The review has determined that the 
items/services at issue in this case are 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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) provided 
April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 20930. The Plan denied your request. The Plan says procedure 
code 20930 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service July 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 2, 2022, billed with 
code 77055. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the service provided does not meet the LCD 
coverage requirements. 
 
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 imaging services provided. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 74-year-old female seen for diagnostic mammography with an out-
of-network physician on August 2, 2022, as part of a planned breast lumpectomy and node biopsy. It was not 
clearly described in the provided documentation that the patient was experiencing an emergency to require this 
mammogram from an out-of-network physician. Therefore, this request will be considered not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on August 2, 2022, billed with code 77055.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a home visit. You say that you have back, and leg pain and you cannot stand 
or walk. You joined the requested office because you were told that a provider would come to your home once 
a month. The Plan denied your request. The Plan says you must receive your care from a network provider. 
You have a network primary care physician (PCP) who is responsible for providing your routine healthcare 
needs and overseeing your care. If you need certain types of covered services or supplies from network 
providers, you must get approval in advance from your PCP (such as giving you a referral). 
 
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 home visit 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 cystourethroscopy, with biopsy(s) rendered on April 20, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says only the most extensive procedure should be reported. 
 
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 52204 is "Cystourethroscopy, with biopsy(s)." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 52204 has a bundled 
relationship with CPT 52214. Per National Correct Coding Initiative (NCCI) rules, a modifier is allowed to unbundle the relationship between the two codes providing the documentation in the enrollee's medical record 
justifies the use of an appropriate modifier. In this case, the medical records provided do not include sufficient 
documentation to validate that CPT 52204 was a distinct/separate procedure and does not meet requirements to 
use a 59 modifier, therefore this procedure cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for cystourethroscopy, with biopsy(s) rendered on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87801, and 87798 billed for 
date of service October 11, 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 payment for code 87481, 87653, and 87798 is bundled into payment for 
code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We looked at the file and the rules. We have confirmed that codes 87481, 87653, and 87798 are column II 
codes to column I code 87801. The codes have not been billed with an appropriate modifier to bypass the edit. 
We also find that code 87801-91 is not supported. The records do not show that code 87801 was a repeat 
procedure. 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 codes 87481, 87653, 87801, and 87798 billed for date of 
service October 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a take-home supply of methadone; up to 7 additional day supply 
(code G2078), Medication assisted treatment, methadone; weekly bundle including dispensing and/or 
administration, substance use counseling (code G2067) and Medication assisted treatment, weekly bundle not 
including the drug, including substance use counseling, individual and group therapy, and toxicology testing if 
performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) (code G2074) 
provided from June 6, 2022, to June 27, 2022. 
 
You asked the Plan to pay for a take-home supply of methadone; up to 7 additional day supply 
(code G2078), Medication assisted treatment, methadone; weekly bundle including dispensing and/or 
administration, substance use counseling (code G2067) and Medication assisted treatment, weekly bundle not 
including the drug, including substance use counseling, individual and group therapy, and toxicology testing if 
performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) (code G2074). You 
say that you are Medicare and an OTP provider. The Plan denied your request. The Plan says that Opioid 
Treatment Program services provided by hospitals, CAHs, and Free-Standing \Opioid Treatment Program 
facilities." Individual provider cannot bill for OTP service. 
 
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 rationale incorrectly states that this claim was submitted by a physician rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for a take-home supply of 
methadone; up to 7 additional day supply (code G2078), Medication assisted treatment, methadone; weekly 
bundle including dispensing and/or administration, substance use counseling (code G2067) and Medication 
assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and 
group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid 
Treatment Program) (code G2074) provided from June 6, 2022, to June 27, 2022.  
 
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 spinal fusion, including any associated procedures, and 
hospital admission (22558, 20930, 22612, 212853 and 22840). 
 
You asked the Plan to pre-approve spinal fusion, including any associated procedures, and hospital admission. 
You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not 
been established. Therefore, coverage criteria have not been met. 
 
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 spinal fusion, including any associated 
procedures, and hospital admission. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a 
recent trial and failure of physical therapy for the back pain.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion, including any associated procedures, and hospital admission have 
not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion, including any 
associated procedures, and hospital admission (22558, 20930, 22612, 212853 and 22840).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on October 
7, 2022, billed with multiple codes including 87801. 
 
You asked the Plan to pay for the UTI panel. You say that this testing as medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare rules. The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UTI panel have not been met. Specifically, the records show that this was a single panel which 
was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to pay for 
the urinary tract infection (UTI) panel provided on October 7, 2022, billed with multiple codes including 
87801.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty surgery. 
 
You asked the Plan to pre-approve kyphoplasty. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for this surgery. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery may be covered if certain 
inclusion criteria are met and exclusion criteria (contraindications) are not 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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for kyphoplasty surgery. Our physician reviewer found the records show that the 
enrollee's fracture is more than 12 weeks old. There is no imaging study showing that there is a new fracture 
less than 12 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty surgery.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xF genetic testing (81455) provided January 4, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you are requesting reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says that the requested test is not reasonable and necessary. 
 
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 pay for the genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a history of urothelial carcinoma. The records indicate 
that the enrollee underwent a left nephroureterectomy on March 20th, 2020. This was followed by post-
operative radiation and chemotherapy. In December of 2020, a left neck biopsy showed urothelial carcinoma. 
A fine needle aspiration of a supraclavicular lymph node on December 9th, 2021, showed malignant cells 
consistent with metastatic high-grade urothelial carcinoma. The review indicates that the requested test was 
medically necessary and reasonable. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for the Tempus xF genetic testing (81455) provided January 4, 2022.  
 
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.