Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRIs. You say that the enrollee has tried conservative management 
without improvement of symptoms. The Plan denied your request. The Plan says that the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRIs. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the records indicate a history of low back and 
left hip pain. She has had a course of PT without improvement. Medical necessity of the requested MRI lumbar 
spine has 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 MRIs have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the lumbar spine.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cerebral perfusion analysis using computed tomography 
(CTP) with contrast administration (0042T) provided on February 12, 2023. 
 You asked the Plan to pay for CTP. You say that this service was medically necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this service was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for CTP. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found information in the coverage criteria specifically state that the test in question is not indicated, with the 
exception of determining endovascular therapy (EVT) in the late time period (6-24 hour) of an acute (<24 hour) 
ischemic stroke (AIS), which the documentation does not support. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CTP have not been met. Therefore, we decided that the Plan does not have to 
pay for cerebral perfusion analysis using computed tomography (CTP) with contrast administration (0042T) 
provided on February 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45380 billed for March 8, 2023. 
 You asked the Plan to pay for procedure code 45380. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for procedure code 45380 is bundled into 
payment for code 45385. 
 
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 45380 is a column II code to column I code 45385; however, 45380 
was billed with a modifier.  
 
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 procedure code 45380. Our reviewer says that procedure 
code 45380 does not meet criteria for payment. Our reviewer found that the procedure at issue was reported 
with modifier XU (unusual non-overlapping service) to bypass the edit with code 45385. The procedure report 
does not support the tumor removal and biopsy was in different anatomical sites or a different patient encounter 
and therefore 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 procedure code 45380 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 45380 billed for March 8, 2023.
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 multiple complex 
medical issues that cannot be managed at a lower level of care and will need ongoing daily physician 
management. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval.  
 
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 that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the cardiovascular appointment with your doctor of choice. 
 
You asked the Plan to pre-approve the cardiovascular appointment. You say that you are appealing the denial. 
The Plan denied your request. The Plan says that that there are approved providers in-network. 
 
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 has not responded to multiple attempts to obtain more information for 
your case. The Plan submitted a copy of your 2022 Evidence of Coverage (EOC); however, this request was 
submitted in the 2023 Plan year. Without a copy of the applicable EOC, we cannot determine whether your 
contract with the Plan includes a network lock-in restriction that would prevent you from utilizing an out-of-
network doctor of your choice. Therefore, the Plan has not shown that its decision to deny authorization for this 
service is correct or justified. Therefore, we decided that the Plan has to pre-approve the cardiovascular 
appointment with your doctor of choice.  
 
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 end-stage renal disease services provided from January 2, 
2023, to January 30, 2023. 
 
You asked the Plan to pay for the end-stage renal disease services. You say that these services were medically 
necessary and should be paid. The Plan denied your request. The Plan says you billed these services with an 
incorrect principal diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital-based and independent renal facilities 
must bill end stage renal disease as the principal diagnosis code on the claim.   In this case, you billed a 
principal diagnosis of E11.22- Type 2 diabetes mellitus with diabetic chronic kidney disease instead of the 
required end stage renal disease.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the end-stage renal disease services have not been met. Therefore, we decided that the Plan does 
not have to pay for end-stage renal disease services provided from January 2, 2023, to January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96365, 96366, 96521) provided on April 13, 
2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 use of codes 96365, 
96366, and 96521, is not supported by the records provided. Our reviewer found that the record states that a 
continuous insulin treatment was performed with glucose monitoring. There is a more specific code to report 
this service. 
 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 the services (96365, 96366, 96521) provided on April 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show the enrollee needs an intensive team for their care. The services 
they need can be provided safely in other settings, for example, a skilled nursing facility, home with home 
health services or home with outpatient therapy. Under Medicare, the request is not medically necessary. 
 
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 there is not a reasonable expectation that this 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 acute IRF admission and services.
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 your physician feels that inpatient rehabilitation will 
give you the care needed. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to an IRF. 
 
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 do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87798 billed for date of service 
January 30, 2023.  
 
You asked the Plan to pay for procedure codes 87481 and 87798. You say that the services at issue were a 
medical necessity for the enrollee. 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 MAI value for the codes at issue is 3. the MUE for CPT code 87481 is 5. You billed 6 units of 
this code, exceeding the MUE. The MUE for CPT code 87798 is 13. You billed 23 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 codes 87481 and 87798 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87481 and 87798 billed for date of service January 30, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty spine surgery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show you have significant 
pain in your low and mid back that shoots down your legs. The examination showed tenderness at the L1 level. 
There is no detailed documentation of worsening pain, progression of body height loss, more than 25 percent 
vertebral body height loss, deformity, or severe impact on daily activities. There is no formal magnetic 
resonance imaging (MRI) provided for review. The criteria for coverage are not met and the kyphoplasty is not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty spine surgery.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 21, 2022, to 
September 19, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was submitted 
timely. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 22, 2022. The NOA was not received by the Plan until May 5, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
August 21, 2022, to September 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93005 billed for date of service February 6, 2023. 
 
You asked the Plan to pay for code 93005. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says this code is not separate payable. 
 
The rules say that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In 
this case, the code in dispute has a status indicator of QI, meaning that it is a STV-packaged service.  This 
disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 93005 have not been met. Therefore, we decided that the Plan does not have to pay for code 
93005 billed for date of service February 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement (TKR). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a TKA is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you are being 
treated for a meniscus tear. You have left knee pain for two weeks. There is no documentation of a trial of 
recent reasonable and comprehensive less-invasive conservative measures. The diagnostic studies of the left 
knee do not clearly support significant osteoarthritis. The records do not support that the criteria for coverage 
are met and that the knee replacement is reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a total knee replacement (TKR).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service April 14, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code is 
not substantiated by the clinical documentation. 
 
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 find that CPT code 99285 is not supported in the medical record. The records show that the enrollee was 
seen for nausea, diarrhea, and abdominal pain. The enrollee was found to have gastroenteritis. The records do 
not show that the enrollee received medical decision making of high complexity. 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 code 99285 billed for date of service April 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 30, 2022, to 
November 28, 2022. 
 You asked the Plan to pay for the home health services. You say that the original NOA submitted was rejected, 
but you have now submitted a correct NOA. The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 30, 2022. The NOA was not received by the Plan until April 21, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 30, 2022, to November 28, 2022.