Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a center mount power elevating leg rest/platform 
(E1012) and electronic connection (E2311). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the items are 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 wheelchair accessories. Our reviewer 
says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the member does not have a musculoskeletal condition or the presence of a cast or brace which 
prevents 90-degree flexion at the knee or have significant edema of the lower extremities that requires an 
elevating leg rest. It is not medically necessary for the member to control power option through separate 
joystick over their own power switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a center mount power elevating leg rest/platform (E1012) and electronic 
connection (E2311).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for imaging on October 07, 2022. 
 
You asked the Plan to waive the copayment for imaging. You say that there should be no copayment for this 
service, and you believe this was a preventable test that was ordered by the doctor. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. You will 
only pay one copayment per day even if multiple diagnostic radiology services are performed. Covered 
services include but are not limited to diagnostic radiology services, such as ultrasound, nuclear cardiac 
imaging, PET, MRI, and CT scan.  
 
 
 You have been asked to pay a $325 copayment for imaging. This item/service falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for imaging on October 07, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc OR Supartz FX first. 
 
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 Euflexxa. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110, 97140, 97530, 97116) provided on 
August 16, 2022. 
 
You asked the Plan to pay for therapy services. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says the principal diagnosis code used on this claim is a sequela 
code, which requires a manifestation code or for the condition or nature of the sequela to be coded and 
sequenced first. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy services have not been met. Specifically, the primary diagnosis code submitted on this 
claim is a sequela code. Generally, a sequela code should be coded second after the condition or nature of the 
sequela is reported. Alternately, some sequela codes may be followed by a manifestation code identified in the 
Tabular List and title or the code may be used alone if the sequela code has been expanded to include the 
manifestations. None of these conditions have been met in this case. Therefore, we decided that the Plan does 
not have to pay for therapy services (97110, 97140, 97530, 97116) provided on August 16, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for code 99285 billed for January 27, 2022, to January 28, 2022. 
 
You asked the Plan to pay for code 99285. The Plan denied your request. The Plan says that code 99285 is 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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires 
these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or 
mental status: 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 presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function". 
 
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 99285. Our reviewer says that the use of code 99285 is 
supported by the records provided. Our reviewer found that CMS requires facilities to create and follow their 
own facility emergency department EM guidelines as there is no standard for these at this time. The appellant's 
appeal states that they have established guidelines for their facility coding and the appeal reflects that they are 
in line with the examples set forth by ACEP (American college of emergency physicians). The records show 
that 99285 was reported appropriately as outlined by the ACEP facility coding guidelines. 
Per the guidelines, the following is from the possible interventions to report 99285: 
 
Prep for special imaging study (CT, MRI, Ultrasound, VQ scan) combined with multiple tests or parenteral 
medication or oral or IV contrast. 
 
The record supports that a CT scan, X-ray, and lab tests were performed at this visit, which meets criteria to 
report code 99285. 
 
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 99285 have been met. Therefore, we decided that the Plan has to pay for 
code 99285 billed for January 27, 2022, to January 28, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 1, 2021, to 
December 10, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of principal diagnosis code A41.9: sepsis unspecified organism with DRG 
853. The Plan denied your request. The Plan says the medical records do not support the billing of principal 
diagnosis code A41.9: sepsis unspecified organism with DRG 853. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the medical records do not support the billing of principal diagnosis code A41.9: sepsis unspecified 
organism with DRG 853. Our physician reviewer found the documentation does not support a manifestation of 
systemic infection beyond that evidenced by SIRS criteria. The enrollee remained hemodynamically stable 
throughout admission with no documentation supporting a dysregulated host response to infection. In this case 
there was no clinical or laboratory evidence of sepsis. The review has determined that the documentation did 
not support A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 1, 2021, to December 10, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 test (99211) provided on August 17, 2022. 
 
You asked the Plan to pay for the COVID-19 test. You say that this service was covered before and should be 
covered. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 COVID-19 test have been met. No 
records were provided to show that this diagnostic test was ordered by a physician. Therefore, we decided that 
the Plan does not have to pay for a COVID-19 test (99211) provided on August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 29, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan made multiple attempts to obtain clinical notes but did not receive any. Therefore, the Plan could not 
review for medical necessity for the visit and removal of skin lesions. Future visits with non-contracted 
providers require prior authorization before your visit. 
 
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 physician's services have been met. 
Therefore, we decided that the Plan does not have to pay for physician's services provided on July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 17, 2022 by an 
out-of-network provider. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says that the Plan 
made multiple attempts to obtain clinical notes but did not receive any. Therefore, the Plan could not review for 
medical necessity. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on August 17, 2022 by an out-of-
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee has tried multiple medications, 
nerve pain medications, muscle relaxants over the counter medications, and topical medications. You also say 
that the enrollee has tried a lumbar medial branch block with benefit, but not significant enough to meet criteria 
for the radio frequency ablation. The Plan denied your request. The Plan says the requested injections are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet all the criteria. 
 
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 injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the provided documentation 
does not indicate the percentage of pain relief. The reviewer found the documentation does not indicate 
functional improvement from the previous medial branch blocks. The reviewer also found the documentation 
does not mention why the enrollee cannot undergo a radiofrequency ablation. Therefore, the reviewer found 
that the requested injections are 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770` billed for date of service August 15, 
2022. 
 
You asked the Plan to pay for procedure code 76770`. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 76770` is bundled into payment for code 93976. 
 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 
76770` is a column II code to column I code 93976. 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 76770` billed for date of service August 15, 
2022.
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 have been able to work with therapy and are 
requiring minimum assistance with functional transfers, bathing, and dressings. You say that you require a 
walker and has been able to walk 4 feet with assistance. You say that you require intensive physician oversight 
of neurological, hemodynamic, and psychological medical management due to your functional impairments 
and medical complexity. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met at an alternate level of care. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service May 21, 
2022. 
 
You asked the Plan to pay for procedure code 71250. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 71250 is bundled into payment for code 71260. 
 
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 71250 
is a column II code to column I code 71260 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 71250 billed for date of service May 21, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on June 27, 
2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services at issue have 
been billed correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee developed weakness from a stroke and 
will benefit from short term rehab to gain the ability to do everyday life and mobility. The Plan denied your 
request. The Plan says the enrollee is unable to participate in or benefit from 15 hours of intensive therapy per 
week and may safely receive the services needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on July 22, 2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the service was medically necessary. 
The Plan denied your request. The Plan says a face-to-face encounter is required for this item, the 
documentation submitted does not include one, so payment is not supported at this time. 
 The Plan must follow Medicare rules. Medicare rules say that this service requires that the treating practitioner 
must have a face-to-face encounter with a beneficiary within the six months prior to prescribing items that 
appear on the Required Face-To-Face Encounter and Written Order Prior To Delivery List. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to 
pay for a lumbar-sacral orthosis provided on July 22, 2022.