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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from July 17, 2021, to July 31, 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 the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our 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 reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that while the documentation from 
7/17/2021-7/31/2021 repeatedly contradicts itself, there is no evidence (orders, care notes) that the enrollee 
received care to the surgical incision during the time period. While it was noted on 7/22/2021 that the enrollee 
was to receive pericare after episodes of incontinence, there is no evidence that this was done. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from July 17, 2021, to July 31, 
2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to hold you harmless for a repair of blepharoptosis, and blepharoplasty procedure, 
provided on July 25, 2022. 
 
You asked the Plan to hold you harmless for a repair of blepharoptosis, and blepharoplasty procedure. You say 
that the services should be covered. The Plan denied your request. The Plan says that this is not a covered 
service. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for a repair of blepharoptosis, and blepharoplasty procedure by a contract provider. The file 
does not show that the Plan provided notice that a repair of blepharoptosis, and blepharoplasty procedure would 
not be covered. Under Medicare rules, this means a repair of blepharoptosis, and blepharoplasty procedure is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for a repair of 
blepharoptosis, and blepharoplasty procedure, provided on July 25, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided 
on August 22, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable 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 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate 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 patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99232 is not supported in the medical record. Specifically, the documentation does not 
support that the enrollee was an inpatient status for this date of service. This means this code is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care 
services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care services coded 99232 provided on August 22, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on July 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this claim is 
inappropriately coded based on the CPT/HCPCS/DX code definition or standard coding guidelines. 
 
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 claim in question was inappropriately coded. However, 
the Plan has not stated what exactly is coded incorrectly on this claim or how the provider can correct the 
claim. Without, supporting documentation, the Plans denial cannot be substantiated. Therefore, we decided that 
the Plan has to pay for the services provided on July 17, 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 pre-approve genicular nerve radiofrequency ablation neurotomy. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation neurotomy. You say that genicular 
nerve radiofrequency ablation neurotomy is medically necessary. The Plan denied your request. The Plan says 
the requested genicular nerve radiofrequency ablation neurotomy does not meet the Plan's Medical Policy 
coverage criteria. 
 
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 genicular nerve radiofrequency ablation 
neurotomy. Our reviewer says that the requested genicular nerve radiofrequency ablation neurotomy is not 
considered medically reasonable and necessary. Our physician reviewer found that genicular nerve blocks and 
genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the 
treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; 
osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; 
or as a treatment for individuals who are not candidates for knee replacement surgery. The review has 
determined that the requested genicular nerve radiofrequency ablation of the right knee 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 genicular nerve radiofrequency ablation neurotomy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation 
neurotomy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the plan's preferred drugs. 
 
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 Gelsyn-3. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer found that the documentation 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred drugs. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for 
lymphedema assessment (93702), 4 visits. 
 
You asked the Plan to pre-approve ImpediMed L-Dex device. You say that the enrollee is at high risk of 
developing lymphedema. You also say that this is medically necessary for the enrollee. The Plan denied your 
request. The Plan says that the requested service is experimental. 
 
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 ImpediMed L-Dex device. Our 
reviewer says that the requested ImpediMed L-Dex device is considered medically reasonable and necessary in 
this case. Our physician reviewer found that breast cancer-related lymphedema (BCRL) represents a significant 
concern for enrollees following breast cancer treatment, and assessment for BCRL represents a key component 
of survivorship efforts. The reviewer found that newer techniques such as bioimpedance spectroscopy (BIS) 
have shown the ability to detect subclinical BCRL, allowing for early intervention and low rates of chronic 
BCRL with Level 1 evidence. Given bilateral breast cancer with surgery and radiation with obesity, the risk of 
BCRL is greatly increased. Therefore, the reviewer found that the requested ImpediMed L-Dex is a standard of 
care and reasonable and 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 ImpediMed L-Dex device have been met. Therefore, we decided that the Plan 
has to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment 
(93702), 4 visits.  
 
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 February 2, 2022, to 
March 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. 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 February 2, 2022, to 
March 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient physician services provided on August 30, 
2022, billed with code 99233. 
 
You asked the Plan to pay for the inpatient physician services. You say that three different providers saw this 
enrollee on the date of service, each from a different specialty. The Plan denied your request. The Plan says this 
claim was denied correctly as it is bundled in services bill on another claim from a provider of the same 
specialty. 
 
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. The rules also say that providers in the same group practice of the same 
specialty must bill as if they are one provider. 
 
We looked at the file and Medicare rules. In this case, the documentation submitted does not include a copy of 
the progress note for the provider whose claim is at issue in this case. Only records from the other provider are 
included. As such, we cannot determine whether these two providers were working under the same or different 
specialties on this date of service. We also do not have evidence to support that the services billed were 
performed without the progress note. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient physician services have 
been met. Therefore, we decided that the Plan does not have to pay for the inpatient physician services 
provided on August 30, 2022, billed with code 99233.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 99292 billed for dates of service 
July 8, 2022 to July 10, 2022. 
 You asked the Plan to pay for procedure codes 99291 and 99292. You say that you would like the medical 
records to be reviewed for payment. The Plan denied your request. The Plan says payment for codes 99291 and 
99292 is bundled into payment for code 93503. 
 
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 codes 
99291 and 99292 are column II codes to column I code 93503. 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 codes 99291 and 99292 billed for 
dates of service July 8, 2022 to July 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual routine physical exam provided on  
September 26, 2022. 
 
You asked the Plan to pay for the annual routine physical exam. You say that you thought that your GYN exam 
was not considered the same type of exam as your PCP annual exam. The Plan denied your request. The Plan 
says according to the Plans claim history, the member had an annual routine preventive physical exam on 
January 12, 2022 (claim number 22025E12447) and the service processed according to the members annual 
routine preventive physical exam with no member responsibility. 
 
The Plan contract covers an Annual Routine Preventive Physical Exam. The Plan says non-Medicare covered 
routine physical exams are covered once every calendar year. 
 
We looked at the file and the Plans rules. The file shows that the Plan benefit was used on January 12, 2022 
and you have exceeded the benefit limit for this exam. Therefore, we decided that the Plan does not have to pay 
for an annual routine physical exam provided on September 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 1, 2022, to 
August 18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
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 August 1, 2022, to 
August 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services, billed with code 99285, for 
services provided on September 14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee presented with a potentially urgent 
medical problem. The Plan denied your request. The Plan says the criteria was not met for code 99285. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which usually includes a presenting medical problem of high severity 
and immediate significant threat to life or physiologic function.  
 We looked at the file, and Medicare rules. The medical records show that the enrollee presented to the 
emergency room with moderate generalized weakness with atrial fibrillation as a contributing factor. The 
records do not show that the enrollee presented with a medical problem of high severity and immediate 
significant threat to life. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room 
services, billed with code 99285, for services provided on September 14, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs Retacrit 
or Procrit. The Plan says that there is no indication the preferred drugs would likely be less effective, and/or 
cause adverse effects for the enrollee. 
 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 Aranesp. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee is noted to have anemia and 
chronic kidney disease. There is no evidence that the enrollee is allergic to or intolerant of the Plan's preferred 
medications. There is no evidence that the enrollee has tried and not responded to these other forms of 
medication. There is no documentation as to why these other forms of medication would not be expected to be 
safe and effective for the enrollee. Therefore, the requested Aranesp is not shown to be currently medically 
necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for procedure code 99152. The Plan denied your request. The Plan says payment for 
code 99152 is bundled into payment for code 45380. 
 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 45380. 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 99152 billed for date of 
service August 4, 2022.