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

 
We decided that the Plan does not have to pre-approve Xifaxan tablets. 
 
You asked the Plan to pre-approve Xifaxan tablets. You say that the enrollee has been on Xifaxan twice daily 
for at least two years. The Plan denied your request. The Plan says Xifaxan is a self-administered drug, and 
does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan tablets.  
 
  Benefits for Xifaxan tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Affinity wound source (CPT Q4159). 
 
You asked the Plan to pre-approve Affinity wound source. You say that Affinity wound source is medically 
necessary. The Plan denied your request. The Plan says the requested Affinity wound source is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Affinity wound source. Our reviewer 
says that the requested Affinity wound source is not considered medically reasonable and necessary. Our 
physician reviewer found the enrollee is a 69-year-old who was diagnosed with basal cell carcinoma who 
presented with open wound complication following surgery. Affinity wound grafting was requested. The 
wound was measured at 4 x 2.5 cm on the enrollees forehead. The guidelines state the wound must be clean 
and free of necrotic debris or exudated, have adequate circulation or oxygenation to support tissue growth or 
wound healing as evidenced by physical examination, and partial or full thickness ulcers, not involving tendon, 
muscle, joint capsule or exhibiting exposed bone or sinus tracts, with a clean granular base unless the Cellular 
or Tissue based Products package label indicates this is approved for use involving tendon, muscle, joint capsule or exhibiting exposed bone or sinus tracts, with a clean granular base. However, the provided 
documentation did not describe the wound in any more detail besides the size and did not clarify the required 
qualities listed above to meet criteria for grafting. Therefore, this request for Affinity grafting will be 
considered not medically necessary based on the provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Affinity wound source have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Affinity wound source (CPT Q4159).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (62321). 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat ESI may be considered medically 
reasonable and necessary when the medical record documents at least 50% of sustained improvement for at 
least three months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a repeat epidural steroid injection have not been met. Specifically, the case record does not 
document sustained improvement for at least three months since the enrollee's initial ESI. A repeat ESI is not 
supported in this situation. Therefore, we decided that the Plan does not have to pre-approve a repeat epidural 
steroid injection (62321).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee's ability to regain maximum function. The Plan denied your request. The Plan says the enrollee does 
not have clinical conditions that cannot be appropriately treated in the current hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99233) provided on October 31, 2022. 
 
You asked the Plan to pay for the hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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 99233 is Subsequent Hospital Care. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, the primary diagnosis code 
does not correctly reflect laterality. Records show left laterality, however the left side diagnosis code was not 
used. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been 
met. Therefore, we decided that the Plan does not have to pay for hospital care (99233) provided on October 
31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 3, 2021, to June 
5, 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 the 
claim was 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 N30.01, described as 
acute cystitis with hematuria. 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 was a 70-year-old female who presented to the facility with 
intermittent left-sided abdominal pain located in her lower quadrant. The enrollee developed gross hematuria 
two to three weeks prior and was placed on antibiotics for a presumed urinary tract infection. Symptoms did 
not improve, and the enrollee presented to the emergency room. The computed tomography scan showed an 
obstructing 13 mm stone with resulting hydronephrosis. The patient was admitted and diagnosed with an 
obstruction of the left ureteropelvic junction due to stone and hydronephrosis of the left kidney. In this case, 
there was no specific laboratory evidence of acute cystitis. While acute cystitis was documented, coding 
guidelines do not support assignment of N30.01.  
 
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 June 3, 2021, to June 5, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the denial of LTACH will prevent the 
enrollee from reaching their full potential. The Plan denied your request. The Plan says the enrollee does not 
have clinical conditions that cannot be appropriately treated in the current hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service October 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 17, 2022, to 
February 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 17, 2022, to 
February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrical stimulator (E0730) provided on September 26, 
2022. 
 
You asked the Plan to pay for the electrical stimulator. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 for the supplies provided in this case. The delivery 
documentation was not itemized and did not describe the specific supplies delivered. 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 an electrical stimulator (E0730) provided on September 26, 2022.
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 services are necessary for the enrollee as they are 
ready to tolerate intensive therapy. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 enrollee does 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 74018. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 74018 is bundled into payment for code 
74240. 
 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 74018 
is a column II code to column I code 74240. 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 procedure code 74018 billed for date of service April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes (A4595) provided on August 27, 2022. 
 
You asked the Plan to pay for the electrodes. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 contain a valid proof of delivery for the supplies provided in this case. Specifically, there was 
a tracking slip from the United States Postal Service (USPS) and a packing slip from the provider which shows exactly what item was shipped. These documents contain the same tracking number, and therefore, is valid 
proof of delivery. Therefore, we decided that the Plan has to pay for the electrodes (A4595) provided on 
August 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 21, 2022 to 
April 19, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 21, 2022 to April 
19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip arthroplasty surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve hip surgery. You say that the enrollee might not be able to walk if this 
surgery is not rendered. The Plan denied your request. The Plan says this provider is out-of-network with the 
Plan and the enrollee can be treated within the Plan network. 
 
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 
hip arthroplasty surgery to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the care needed. The Plan denied your request. The Plan says that they recommend the 
enrollee continue care in the hospital at this time. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. 
 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the spine provided 
on August 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied 
your request. The Plan says services should be received from network providers, except when urgent or an 
emergency. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The provider at issue in this case is not a network provider with the Plan. 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 MRI. Our reviewer says that the records do not indicate that the care 
provided was medically necessary. Our physician reviewer found the exam was not done on an emergency 
basis. It would have been medically reasonable to delay services until the enrollee returned to the service area. 
 
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 MRI have not been met.  
 
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 pay for the MRI. Therefore, we decided that the Plan does not have 
to pay for a magnetic resonance imaging (MRI) of the spine provided on August 12, 2022, by an out-of-
network (OON) provider.