Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 11, 2021, to July 
30, 2021, at the Patient-Driven Payment Model (PDPM) score originally billed. 
 You asked the Plan to pay for home health services at the PDPM score originally billed. You say that the 
services at issue have been billed correctly. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that certain data elements are required for home 
health services. Any claim with incomplete, missing, or invalid information for all of these elements may be 
returned as unprocessable. 
 
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 home health services at the PDPM score originally billed. 
Our reviewer says that the services at issue do not meet criteria for payment at the PDPM score originally 
billed. Our reviewer found that the available documentation does not support that the correct PDPM score was 
submitted by the skilled nursing facility. The documentation available for review does not support that the 
member received or required complex wound care to a surgical wound. The 3rd alphanumeric character in the 
PDPM score is not correct. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services at the PDPM score originally billed have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided from July 11, 2021, 
to July 30, 2021, at the Patient-Driven Payment Model (PDPM) score originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rental charge for a transcutaneous electrical nerve 
stimulator (TENS) unit for the month beginning on October 22, 2022. 
 
You asked the Plan to pay for the TENS rental charge. You say that the services were medically necessary and 
ordered by the treating provider. The Plan denied your request. The Plan says the documentation submitted did 
not include a valid Proof of Delivery, or a Delivery Ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The proof of delivery submitted does not indicate what delivery 
service was used. As such, it cannot be confirmed that it is legitimate. In addition, no progress note from 
around the date in which the order was signed is included in the file. The notes that are included do not make 
any mention that the enrollee has been prescribed or is using a TENS unit. The notes indicate that only 
medications are being used to treat her pain. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
rental charge for a transcutaneous electrical nerve stimulator (TENS) unit for the month beginning on October 
22, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Korsuva. 
 
You asked the Plan to pre-approve Korsuva. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Korsuva. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the review has determined that the 
documentation supports that the Korsuva is medically reasonable and necessary and safe and effective for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Korsuva have been met. Therefore, we decided that the Plan has to pre-approve 
Korsuva.  
 
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: 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 the enrollee was completely independent prior to 
hospitalization and active out in the community and currently needs speech, physical and occupational therapy. 
The Plan denied your request. The Plan says the enrollee's records do not show to have complex rehabilitation 
needs requiring frequent evaluation by a rehabilitation doctor. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PBT (77525). 
 
You asked the Plan to pre-approve the PBT. You say that the enrollee has ongoing rectal bleeding and is at 
significant risk of obstruction requiring an emergency colostomy. The Plan denied your request. The Plan says 
PBT is unproven and unproven or experimental treatments cannot be covered except in special circumstances. 
 
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 PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no compelling reasons offered for why stereotactic radiotherapy (SRT) would be 
needed over more standard approaches of radiation delivery or surgical approaches. Our physician reviewer in 
this case is unfavorable due to lack of demonstration of need for SRT versus traditional external beam radiation. 
 
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 PBT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the PBT (77525).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve the radiation therapy. You say that the services are medically necessary. The 
Plan denied your request. The Plan says there is not enough medical evidence to show that this type of 
radiation treatment is effective to treat the enrollee's skin cancer. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found billing for daily image-guided radiation therapy (IGRT) which would not be 
furnished in accordance with accepted standards of medical practice. 
 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 radiation therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the ultrasound guided radiation therapy (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152-59 provided on October 19, 2022. 
 
You asked the Plan to pay for procedure code 99152-59. You say that the medical records support the use of 
modifier 59 with code 99152. The Plan denied your request. The Plan says the medical records do not support 
the use of modifier 59 with code 99152. 
 
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 99152 is a column II code to column I code 45385; however, 99152 
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 99152-59. Our reviewer says that the medical 
records do not support the use of modifier 59 with code 99152. Our reviewer found the procedure report 
describes a colonoscopy with biopsy, and sedation. In this case there is a more appropriate code to report for 
sedation for the gastrointestinal service performed. Therefore, code 99152 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 99152-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99152-59 provided on October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (0241U) provided on November 22, 
2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (0241U) 
provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the IMRT (77386, 77387 and G6002). 
 
You asked the Plan to pre-approve the IMRT. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that there is no direct medical evidence in your case to show that this type 
of radiation treatment is effective to treat the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found from the provided records, IMRT is plausibly a more effective manner to treat the target and to 
spare the surrounding normal tissues than 3D conformal radiation, which is supported by published data. The 
need for IMRT is adequately justified in the case records. Our physician reviewer's decision is therefore 
favorable as our physician reviewer believes IMRT would be within accepted standards 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 the IMRT have been met. Therefore, we decided that the Plan has to pre-
approve the IMRT (77386, 77387 and G6002).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and 
appropriate. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing (81479) provided on December 31, 
2022. 
 
You asked the Plan to pay for the PrismRA testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA testing have not been met. Therefore, we decided that the Plan does not have to pay for the PrismRA testing (81479) provided on 
December 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman device. 
 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that this will be used in conjunction with an open back surgery or 
in conjunction with a spine surgeon. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. According to the Food and Drug Administration (FDA), the HA Minuteman G3-R MIS Fusion Plate 
is a posterior, non-pedicle supplemental fixation device, intended for use at a single level in the non-cervical 
spine (T1-S1). The HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft material and is 
not intended for stand-alone use. In addition, fusion indications within guidelines/literature for (existing or 
potential intraoperative) instability have not been documented and/or met in this case. In addition, there are 
multiple alternate pain generators plausibly significantly contributing to the clinical condition that have not 
been fully documented as having been excluded and/or ruled out. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested Minuteman (Spinal Simplicity interspinous-interlaminar fusion device), in this case, 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Minuteman device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service August 6, 2022. 
 
You asked the Plan to pay for code 99223. You say that the records support payment of this code. The Plan 
denied your request. The Plan says code 99223 billed for date of service August 6, 2022, is not supported by 
the medical record because the records don't support medical decision making of high complexity. 
 
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 care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history, a 
comprehensive exam, and medical decision making of high complexity 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for code 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found the member is an 84-year-old male with a medical history 
including cardiac disease with previous bypass surgery and previous femoral fracture who was admitted to the 
hospital with left wrist pain and paralysis and ambulatory dysfunction. He was seen and examined on August 6, 
2022, by cardiology for nausea. The member was medically stable and did not have any complications. The 
documentation available for review does not support the encounter required decision making of high 
complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service August 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 25, 2022, to September 7, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not covered 
when provided by a non-contract provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided on August 25, 2022, to September 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99220, 99497) provided on July 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
payable.  
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 99220 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit". 
 
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 code 99220 is 
not supported by the records provided. Our reviewer found that the submitted documentation does not indicate 
that the encounter required medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99220 have not been met. 
 
We have also confirmed that code 99497 is a column II code to column I code 99220. This claim has not been 
billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for the services (99220, 99497) 
provided on July 25, 2022.