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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 
24, 2021, through November 22, 2021. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were no longer medically necessary as there was no need for daily 
skilled nursing or therapy needed. 
 
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 require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (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 October 24, 2021, through November 22, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99222-57 billed for date of service August 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim is payable. The Plan denied your 
request. The Plan says that the payment for service is included in the fee for the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The file shows that code 99222 was billed on the same day as major procedure code 43840. We find that CPT 
code 99222 is supported in the medical record. The medical records show that the evaluation resulted in the 
decision to perform surgery, identified by modifier -57 on the claim. Based on this information, we decided 
that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99222-57 billed for date of service August 2, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 99306. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says the code used to report the services provided is not 
supported in the medical records. 
 
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 99306 is initial nursing facility 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 are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility 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 procedure code 99306. Our reviewer says that the code used 
to report the services provided is not supported in the medical record. Our reviewer found the records provided 
contain no clear documentation that the encounter required medical decision making of high complexity. 
Therefore, all the necessary criteria for reporting code 99306 are not met in this case. 
 
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 99306 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99306 billed for date of service April 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says your request is not medically necessary. 
 
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 complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cone beam (D0365), treatment simulation (D0393), 
an unspecified preventive procedure (D1999), the surgical placement of implant bodies (D6010), and 
extractions (D7140) for tooth #21, #22, #23, #24, #25, #26, #27, and #28 provided by an out-of-network 
provider on November 30, 2022. You asked the Plan to pay more for the dental services. You say that there are no in-network providers within 
your service area. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. Also, 
the denial of payment for the cone beam, treatment simulation, unspecified preventive procedure, and surgical 
placement of implant bodies is correct because they are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the extractions (D7140). This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The cone beam, treatment simulation, unspecified preventive procedure, and surgical 
placement of implant bodies are not covered under the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pay more for a cone beam (D0365), treatment simulation (D0393), an unspecified 
preventive procedure (D1999), the surgical placement of implant bodies (D6010), and extractions (D7140) for 
tooth #21, #22, #23, #24, #25, #26, #27, and #28 provided by an out-of-network provider on November 30, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis. 
 You asked the Plan to pre-approve a knee orthosis. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that knee orthoses are only covered for certain 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a knee orthosis. Our reviewer says that 
the documentation does not support that the requested item is medically reasonable or necessary. Our physician 
reviewer found the documentation notes that the enrollee has normal gait. A medical progress note on 
September 13, 2022, states that the enrollee has arthralgia in the knees that is aggravated by long periods of 
sitting. Collateral ligaments are intact medially and laterally, range of motion is normal. Drawer test is 
negative. Patellofemoral joint without crepitations. Apley test is negative. The enrollee's diagnosis is knee 
arthritis. The enrollee is ambulatory, but the documentation does not reveal evidence of a knee contracture, 
objective joint laxity or instability on a physical examination. Therefore, the enrollee does not meet criteria for 
the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital admission provided from December 16, 2022, to 
December 18, 2022. 
 
You asked the Plan to pay for the inpatient hospital admission. You say that you do not feel you have received 
a fair review. You also say that the correct information has been provided to reflect the appropriate diagnosis 
and treatment. The Plan denied your request. The Plan says that this service was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 admission. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 inpatient hospital admission have been met. Therefore, we decided that the 
Plan has to pay for the inpatient hospital admission provided from December 16, 2022, to December 18, 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 procedure code 86077 billed for date of service November 
23, 2022. 
 You asked the Plan to pay for procedure code 86077. You say that the services were 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 November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies (K0553) provided on December 16, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says a proof of delivery was 
not submitted. 
 
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 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 supplies (K0553) provided on December 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carfilzomib. 
 
You asked the Plan to pre-approve carfilzomib. 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 Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve carfilzomib. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of carfilzomib is not 
FDA-approved for the enrollees diagnosis in combination with venetoclax. The use is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of carfilzomib have not been met. Therefore, we decided that the Plan does not 
have to pre-approve carfilzomib.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You did not provide a specific argument with your appeal request. 
The Plan denied your request. The Plan says image-guided radiation therapy (IGRT) is not medically 
necessary. Use of daily imaging is not backed up by any known data and would be non-standard. Weekly 
imaging is the standard of care. The patient is currently receiving standard radiation therapy. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT for whole breast radiation is an accepted standard for exceptional circumstances such as 
difficult patient set-up, prior radiation necessitating more accurate localization, abutment of the field against a critical organ (such as heart in left sided breast cancers). Another rationale would be initial set-up errors 
necessitating serial imaging. There is no rationale offered for IGRT in this case. The routine use of IGRT is not 
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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to a Long-Term Acute Care 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 the enrollee is a 74-year-old male who was admitted to the acute care hospital with 
gangrenous cholecystitis requiring percutaneous tube placement, antibiotics, surgical removal of infected 
peritoneal dialysis catheter but it progressed to require cholecystectomy, drain placement, extended antibiotics, TPN, sandostatin, and wound care for a foot wound. Recent notes describe the enrollee as stable and improving 
with current treatment without plans for additional surgeries or extended care.  
1. The enrollee appears to be improving with treatment and should only require short-term additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for a lower level of 
care. The enrollee does not require services at the LTACH that are not already available at the current facility.  
2. There are no services at the LTACH that the enrollee requires that are not already available and covered at 
the current facility.  
3. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95910 billed for date of service September 
28, 2022. 
 
You asked the Plan to pay for procedure code 95910. You say that this code should be processed for additional 
payment. The Plan denied your request. The Plan says payment for code 95910 is bundled into payment for 
code 95870. 
 
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 95910 
is a column II code to column I code 95870 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 95910 billed for date of service September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U billed for date of service December 
28, 2022. 
 
You asked the Plan to pay for the billed services. You say that supporting documentation was provided. 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. A 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 the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0241U 
billed for date of service December 28, 2022.