Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an assistant surgeon for partial mastectomy (19301) provided 
on November 16, 2022.  
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says services of an assistant surgeon, co-surgeon, or surgical team are not covered for this 
procedure. 
 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 19301. 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 physician reviewer found 
the available documentation in the case file does not support that an assistant surgeon was medically necessary 
in this case.  
 
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 an assistant surgeon for partial mastectomy (19301) provided on November 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 1, 2021 to July 3, 
2021, 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 this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical and 
coding validation audit was performed to help ensure that the diagnosis codes on the claim were supported 
clinically. 
 
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 DRG 091. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported. Our physician reviewer found that the enrollee was 
hospitalized with stroke-like symptoms and a chronic heel ulcer.  Shew was ruled out for both a stroke and 
osteomyelitis. The enrollee was treated for a urinary tract infection (UTI) and acute kidney injury (AKI), with 
resolution of the symptoms. A specific diagnosis regarding her acute stroke-like symptoms is not noted, but is 
most likely attributable to a transient ischemic attack (TIA), her UTI (infectious encephalopathy, delirium) or 
her AKI (metabolic encephalopathy), rather than just an other nervous system diagnosis. The billing of 
R29.818 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 1, 2021 to July 3, 2021, at the Diagnosis Related Group (DRG) 
originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the second opinion with an OON provider. You say that the requested OON 
neurologist is specialized in memory disorders.  The Plan denied your request. The Plan says the care needed 
can be provided in-network.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 second opinion with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met.  Our physician 
reviewer found the Plan has readily identified other in-network neurologists who would be capable of 
evaluating the enrollee's condition/complaints.  There is no evidence of network insufficiency. The enrollee is 
undergoing evaluation for mild cognitive impairment (MCI.) This is not a complex or unique clinical 
presentation that readily necessitates tertiary evaluation, nor were there any other unique features presented to 
warrant OON services. 
 
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 second opinion with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a second opinion with an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve OON physical therapy. You say that you have visited numerous providers 
that are in-network and have found the level of care and the results subpar as opposed to the service you have 
experienced at the requested OON provider. The Plan denied your request. The Plan says you must use network 
providers to get health care and services when there are network providers available. 
 
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 
physical therapy 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 procedure code 90834 provided from November 2, 2022, to 
December 8, 2022. 
 
You asked the Plan to pay for procedure code 90834. 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 looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes F31.81 and F33.2 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure code 90834 provided from November 2, 2022, to December 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490 for date of service March 2, 2023. 
 
You asked the Plan to pay for code J3490. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are included in the global surgical package. 
 
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 J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as surgery procedure 62323. This means code J3490 is included in the global surgery 
period as code 62323. Without an appropriate modifier, the claim is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of code J3490 have not been met. Therefore, we 
decided that the Plan does not have to pay for code J3490 for date of service March 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22515, 22513) 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation (PVA) for 
Osteoporotic Vertebral Compression Fracture (VCF) is covered when specific criteria is 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 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding the noted compression fractures being acute or subacute. The diagnostic imaging does not indicate 
this and the exam notes that you have had the pain for greater than 2 months. The pain is not worsening, and 
you have not been hospitalized. Additionally, the compression fractures are not corroborated by the magnetic 
resonance imaging (MRI) on May 22, 2023, to have progressed and the fracture involving the T10 vertebral 
body was not documented to be greater than 25%. Therefore, you do not meet the coverage criteria detailed in 
the LCD. 
 
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 (22515, 22513)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing panel provided on August 1, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the panel should be 
billed with one code. 
 
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. In this case, the panel was not billed with one unit of one code as 
required by A58710. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing panel provided on 
August 1, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) 
provided on October 24, 2022. 
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this is a covered code.  
The Plan denied your request. The Plan says that ordering a multi-class panel of definitive (confirmation) urine 
drug tests that are not used in clinical management, exceeds the needs of the enrollee. Under Medicare rules, 
the number of definitive urine drug classes requested are not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when medically necessary 
according to the rules in the Local Coverage Determination. 
 
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 definitive UDT for 15-21 drug classes. 
Our reviewer says that this testing was medically reasonable and necessary. Our physician reviewer found that 
the enrollee has chronic pain and is prescribed Alprazolam and Oxycodone. The UDT is partially inconsistent, 
and she is at high risk by the morphine milligram equivalent (MME) scale. The testing was 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 the definitive UDT for 15-21 drug classes have been met. Therefore, we 
decided that the Plan has to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) 
provided on October 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00400 billed for date of service December 
15, 2022. 
 
You asked the Plan to pay for procedure code 00400. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 00400 is: Anesthesia for procedures on the integumentary 
system on the extremities, anterior trunk and perineum; 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 procedure code 00400. Our reviewer says that procedure code 00400 does not meet criteria for payment. Our reviewer found that the provider reported 218 units for the 
service at issue. After careful review of the anesthesia report, the procedure 1 start time and procedure 1 stop 
time are not legible 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 00400 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 00400 billed for date of service December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection (ESI).  
 
You asked the Plan to pre-approve a repeat ESI. You say that the enrollee is approaching three months since 
the last injection in February 2023. You say that the enrollee had greater than 50% relief. You also say that this 
will help the enrollee live their daily life. The Plan denied your request. The Plan says a repeat ESI is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESI. Our reviewer says that the 
request for a repeat ESI is not medically necessary. Our physician reviewer found the provided documentation does not indicate that at least three months have passed since the previous injection. Therefore, the reviewer 
found that a repeat ESI is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat lumbar epidural steroid injection (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat right cervical radiofrequency ablation (64633, 
64634). 
 
You asked the Plan to pre-approve the injection procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the requested cervical 
radiofrequency ablations at the C4-C5 and C6-C7 levels is considered 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 injection procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has had radiofrequency ablation (RFA) of the cervical branches in the 
past, but the dates and the degree and duration of those treatments are not documented at all. The lack of documentation as to when the last RFA was performed, the degree and duration of pain relief is essential to 
evaluating the effectiveness of this therapy. Therefore, at this time, 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 the injection procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repeat right cervical radiofrequency ablation (64633, 64634).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve the dental services. You say that you are halfway done with this treatment. 
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 with the approval of four dental implants. 
Therefore, we decided that the Plan does not have to pre-approve dental implants.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the use of this drug is not reasonable and necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested use of Keytruda is not FDA-approved for the enrollees diagnosis. Our physician reviewer found the 
use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an Accu-Chek meter and test strips. 
 
You asked the Plan to pre-approve the equipment. The Plan denied your request. The Plan says that the 
coverage criteria are not met. 
 
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 argues that the coverage criteria are not met and made its determination 
on records provided. However, the Plan has not provided these records for review in the case file. Please note 
that a request for medical records was faxed to the Plan on June 16, 2023, and a response was not received. 
Therefore, we decided that the Plan has to pre-approve an Accu-Chek meter and test strips.  
 
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 computerized dynamic posturography sensory organization 
test (CDP-SOT) (92548) provided on August 16, 2022. 
 
You asked the Plan to pay for CDP-SOT. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the service at issue is experimental/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 CDP-SOT. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that after a review of the available literature, this testing method, although promising, does not have 
sufficient high-quality evidence to generally support its use in the enrollee's clinical situation. There is not 
sufficient evidence of the test leading to improved overall outcome measurements. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CDP-SOT have not been met. Therefore, we decided that the Plan does not 
have to pay for computerized dynamic posturography sensory organization test (CDP-SOT) (92548) provided 
on August 16, 2022.