Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic Inj 4mg/3ml. 
 
You asked the Plan to pre-approve a prescription drug. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee does not have Part D pharmacy (drug) benefit administered by 
the Plan. Drugs covered under Part D are not eligible for coverage under Part B benefit. 
 
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 Ozempic Inj 4mg/3ml.
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 requested services are necessary for the enrollee. 
The Plan denied your request. The Plan says the requested services are 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 the provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291 X 4) provided from May 13, 
2022, through May 16, 2022. 
 
You asked the Plan to pay for the critical care services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
did not support a critical care visit of 30-74 minutes was performed on the billed dates of service. The 
documentation does not include the time spent providing this service; therefore, the billed Critical Care 
Evaluation and Management code cannot be verified. Therefore, we decided that the Plan does not have to pay 
for the critical care services (99291 X 4) provided from May 13, 2022, through May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection procedure; radioactive tracer for identification of 
sentinel node (CPT code 38792) provided on April 21, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered 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. The rules say diagnosis codes are to be used and 
reported at their highest number of characters available and to the highest level of specificity documented in the 
medical record. 
 
Review of the file shows that the diagnosis code that was billed was Z01.818 -Encounter for other 
preprocedural examination. This diagnosis code does not verify anything about why the procedure was 
medically necessary; therefore, the services were not reported correctly. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for injection procedure; radioactive tracer for identification of sentinel node (CPT code 38792) 
provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative therapy. You say 
that the requested service is a safer alternative to a more invasive procedure. You also say that this is safe and 
effective. The Plan denied your request. The Plan says the requested service is considered investigational. The 
Plan also says that the requested service 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 Vertiflex. Our reviewer says that the 
requested Vertiflex device not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested Vertiflex device is considered experimental. Therefore, the reviewer found that 
the requested Vertiflex device is not medically 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vertiflex Superion device (22869).
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. 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 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 in this case, the complexity of your nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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, 
at an intensive rehabilitation therapy program. You can receive further services at a lower 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from June 8, 
2022, to July 7, 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 the Notice of Admission (NOA) is required to process this claim. 
 
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 would have needed to send in a Notice of Admission for the services. Therefore, we decided that the 
Plan does not have to pay for home health services provided to the enrollee from June 8, 2022, to July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography (93458). 
 
You asked the Plan to pre-approve the physician service. You say that due to likely anginal symptoms and 
significant risk factors, the left heart catheterization was ordered. The Plan denied your request. The Plan says 
the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that left heart catheterization is indicated for the diagnosis 
of, or treatment planning in patients with myocardial abnormalities or dysfunction, valvular dysfunction, 
intracardiac shunts, congenital heart abnormalities, cardiac trauma, or pericardial tamponade. 
 
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 physician service. Our reviewer 
says that the left heart catheterization is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee has had a stress test or coronary computed tomography (CT) 
angiography. The reviewer found that the documentation does not support the rationale for this invasive 
imaging study. The reviewer found that the guidelines do not support a need for cardiac catheterization in this 
setting. Therefore, the reviewer found that cardiac catheterization with coronary arteriography would not be 
considered medically appropriate and necessary at this time. 
 
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 physician service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve catheter placement in coronary artery(s) for coronary angiography (93458).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 29823-51-RT billed for date of service June 28, 2022. 
 
You asked the Plan to pay for code 29823-51-RT. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says code 29823-51-RT is not supported by the medical 
record. The operative report did not include documentation of this 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. 
 
In this case, the CPT Code Manual definition of code 29823-51-RT is surgical shoulder arthroscopy, with 
extensive debridement, including 3 or more discrete structures (humeral bone, humeral articular cartilage, 
glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, 
articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 29823-51-RT. Our reviewer says that code 29823-51-
RT is not supported by the medical record. Our reviewer found the operative report describes debridement of 
long head of biceps tendon and superior glenoid tubercle. The operative report documents "Extensive debridement:  Utilizing a motorized shaver as well as a limited radiofrequency wand, rotator interval was 
further developed.  As expected, that comma could be pulled out more laterally.  The less tuberosity was 
exposed.  The subscapularis could sit down onto the lesser tuberosity and the supraspinatus has a portion which 
still seemed to be attached.  An accessory portal was placed through the torn aspect of the superior rotator cuff. 
This was in more the mid portion and poster or aspect of the supraspinatus. The remaining ruptured log head of 
biceps tendon was debulked and debrided. The plane between the under surface of the rotator cuff and the 
labrum was further developed. Superior glenoid tubercle was debrided and dusted for healing."  In this case per 
CPT code description "including 3 or more discrete structures (humeral bone, humeral articular cartilage, 
glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, 
articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 29823-51-RT have not been met. Therefore, we decided that the Plan does 
not have to pay for code 29823-51-RT billed for date of service June 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from November 23, 2021, to 
December 3, 2021. 
 
You asked the Plan to pay for inpatient care. You say that these services were necessary and should be paid. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 5, 2022, at the billed Diagnosis Related Group (DRG). Comparison of the 
two claims shows these are exact duplicates. There is no evidence presented to support that the billed 
items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital care provided from November 23, 2021, to December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) provided on August 
11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the acupuncture services. You say that you feel that the service should be 
covered The Plan denied your request. The Plan says the enrollees wellness allowance has been exhausted. 
Non-emergent services with non-contracted providers require prior authorization before services being 
rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. Page 67 of the EOC says that the Plan covers acupuncture services for chronic low back 
pain. Acupuncture for psoriasis is not covered. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 
minutes (97810) provided on August 11, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
May 23, 2022. 
 
You asked the Plan to pay for procedure code 88341 and 88342. You say that these services should be paid 
separately. The Plan denied your request. The Plan says payment for codes 88341 and 88342 is bundled into 
payment for code 88360. 
 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 
88341 and 88342 are both column II codes to column I code 88360. 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 88341 and 88342 billed for 
date of service May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Proteor Plie 3 microprocessor knee (L5856 + L5828 + 
L5845 + L5848 + L5850). 
 
You asked the Plan to pre-approve a Proteor Plie 3 microprocessor knee. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 Proteor Plie 3 microprocessor knee. 
Our reviewer says that this item is not medically necessary. Our physician reviewer found the documentation 
doesn't support that the member is a K3 level ambulator.  Additionally, there is no clear documentation to 
indicate a need for a microprocessor knee instead of a mechanical knee. 
 
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 Proteor Plie 3 microprocessor knee have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Proteor Plie 3 microprocessor knee (L5856 + L5828 + L5845 + 
L5848 + L5850).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on March 
20, 2022, to April 18, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 find that CPT codes G0299, & Q5001 is not supported in the medical record. Specifically, the date of 
admission on the submitted Notice of Admission does not correspond with the admission date in the claims 
history. Based on this information, we decided that Medicare rules for coverage of the home health services 
have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0299, 
Q5001) provided on March 20, 2022, to April 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
November 22, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the continued services are not medically necessary. 
 
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 pre-approve 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 records do not show that you need intravenous (IV) medications, new ostomy 
care, daily complex wound care, or respiratory care. You do not require skilled nursing on a daily basis. 
Although the records show that you are very limited functionally, your functional status is close to your 
baseline level of function. You do not require skilled therapy on a daily basis. As a practical matter, you do not 
require the necessary services on an inpatient basis at the SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued skilled nursing facility (SNF) care beyond November 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy services. You say that it would be beneficial for the 
enrollee to attend physical therapy as close to their residence as possible. The Plan denied your request. The 
Plan says there are multiple in-network providers available for the enrollee to choose from. 
 
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 
the physical therapy services to be provided by an out-of-network (OON) provider.