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

 
We decided that the Plan does not have to pay for marsupialization of cyst or abscess of liver provided to the 
enrollee on December 29, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 47300 (1 unit) remains 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. 
 
In this case, the CPT Code Manual definition of code 47300 is "Marsupialization of cyst or abscess of liver." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there is no documentation of 
marsupialization of cyst or abscess of the liver. The requested procedure is not supported by any medical 
documentation. 
 
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 marsupialization of cyst or abscess of liver provided to the enrollee on December 29, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ranibizumab (Lucentis) (J2778) and the eye drug 
injection (67028). 
 
You asked the Plan to pre-approve Lucentis and the injection. You say that you have had four treatments so far, 
and they have been working for you. You also say that the brand name is more effective than the generic. The 
Plan denied your request. The Plan says this request does not meet the Medicare or health plan coverage 
criteria.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Lucentis and the injection. Our 
reviewer says that you do not meet the criteria for coverage for Lucentis. Our physician reviewer found the 
Plan requires a trial of Eylea before they will approve the requested drug. In this case, you have not tried and 
failed the required drug. Our reviewer also found that the Plans required drug would likely be less effective 
and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis and the injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Ranibizumab (Lucentis) (J2778) and the eye drug injection (67028).
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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that the documentation does not support medical necessity for admission to an IRF. 
The enrollee has no medical acuity or complexity and no acute rehabilitation nursing needs for an IRF 
admission. While the enrollee would benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing 
facility after planned surgery. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service June 5, 2022 
to June 7, 2022. 
 
You asked the Plan to pay for procedure code 99497. You say that the claim was billed correctly. The Plan 
denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223.  
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service June 5, 2022 to 
June 7, 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 1, 2022 to 
January 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. 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 1, 2022 to 
January 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on January 15, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service was billed without anesthesia minutes. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
provider did not send in any documentation of the anesthesia minutes. This information is needed for this code 
and was not provided.. Therefore, we decided that the Plan does not have to pay for anesthesia services 
provided to the enrollee on January 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee underwent cardiac catheterization and percutaneous coronary intervention. 
Repeat catheterization in January 2022 was performed, and the enrollee was offered coronary artery bypass 
surgery (CABG) surgery, which was decline. The follow-up visit in July 2022 showed no change in symptoms 
or clinical status. As such, the medical records provided do not support the rationale for this invasive imaging 
study at this time. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this 
time cardiac catheterization would not be considered medically appropriate and necessary in this patients 
clinical management. 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cardiac catheterization.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 6, 
2020 to May 23, 2020. 
 You asked the Plan to pay for SNF care. You say that you believe the documentation provided will support the 
services rendered and billed. The Plan denied your request. The Plan says without therapy orders and a plan of 
care, the reasonableness and necessity of the SNF services provided could not be determined. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 6, 2020 to May 23, 2020.
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 will benefit from LTACH 
care. The Plan denied your request. The Plan says LTACH care is not medically necessary. 
 
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 the enrollee appears to not be stable for transfer and requires short-term additional 
acute care services that can safely be provided at the current facility. Transfer to the LTACH would not be 
clinically advantageous at this time and completion of treatment at the current facility is recommended.  
 
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: 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 you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the enrollee does 
not meet the Medicare criteria for LTACH services. 
 
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 the documentation does not support that the enrollee has need for complex 
medical treatment in a LTACH.  The enrollee does not require services at the LTACH that are not available at 
the acute care hospital or the skilled nursing facility. The enrollee has improved medically and can receive 
further care at the current acute care hospital or a lower level of care when deemed appropriate. 
 
 
 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on July 1, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
this service was medically necessary due to the constant need for supervision based on weakness. The Plan 
denied your request. The Plan says the information provided does not support ambulance transport to or from 
the facility, which is not a covered destination. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation by ambulance from the hospital to the 
enrollees residence was not medically necessary. Our physician reviewer found the enrollee did not require the 
expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Transportation could have been provided by other means (stretcher van, wheelchair van, private car, 
taxi) without endangering the enrollees condition. Our reviewer also found that a prudent layperson would not 
believe that immediate medical attention was required for someone who was being discharged from the 
hospital. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on July 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says services after December 21, 2022 are not authorized. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that based upon a review of the records provided it was not expected this enrollee would improve in a reasonable period of time 
beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, 
auditory or visual hallucinations or abnormal behaviors. The health plans denial of continued inpatient 
psychiatric services appears appropriate. 
 
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 pre-approve continuation of inpatient mental health services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 7, 2022, to 
August 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. 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 July 7, 2022, to August 
5, 2022.
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. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
already available and covered at the current facility.  Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable heart monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient had no history of atrial fibrillation, nor were any significant cardiac arrhythmias noted on 
electrocardiogram (ECG) monitoring. A recent randomized clinical trial found that continuous monitoring for 
atrial fibrillation with an ILR (implanted loop recorder) (followed by treatment with oral anticoagulation if 
atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable heart monitor.