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

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on June 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99239 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation 
that more than 30 minutes of discharge services were spent on the enrollee. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital discharge services rendered on June 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of Vertiflex Superion device. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that experimental and investigational procedures are not covered by Medicare. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Vertiflex device 
is experimental. More research is needed. Our physician reviewer found that your condition does not meet 
criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of Vertiflex Superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pedal exerciser. 
 
You asked the Plan to pre-approve a pedal exerciser. You say that you would like this post-surgery. The Plan 
denied your request. The Plan says that this is a non-covered service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a pedal exerciser.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement rendered on August 31, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 11720 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
 
 
 The provider submitted a claim for procedure codes 11720 (debridement, 1-5 nails) and 11719 (trimming of 
nails, any number). Code 11720 is a column II code with a modifier indicator of 1 when billed with column I 
code 11719. Code 11720 was not billed with an appropriate modifier to allow for separate payment. Therefore, 
we decided that the Plan does not have to pay for the nail debridement rendered on August 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer for the enrollee. 
 
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Injectafer. Our reviewer says that 
Injectafer is not medically reasonable and necessary. The Plan requires a trial of Infed (iron dextran) and 
Venofer (iron sucrose) before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the 
enrollee's condition does not meet step therapy criteria for Injectafer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer for the enrollee.
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 for the enrollee. 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that medical need 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.  The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke 
and ataxia. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service August 2, 
2021. 
 
You asked the Plan to pay for procedure code 11721. You say that these services were provided in good faith. 
The Plan denied your request. The Plan says payment for code 11721 is bundled into payment for code 11719. The Plan also says that this edit has a modifier indicator of '0', meaning that no modifiers are permitted that will 
change the bundling rules. 
 
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 11721 
is a column II code to column I code 11719. 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 11721 billed for date of 
service August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a medical eye exam provided on November 
5, 2021. 
 
You asked the Plan to waive the deductible for a medical eye exam. You say that you have had a regular 
checkup with the same ophthalmologist every year and are usually charged a $10 copayment. The Plan denied 
your request. The Plan says the deductible applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to outpatient physician services 
provided by an ophthalmologist or optometrist for the diagnosis or treatment of diseases and injuries of the eye, 
including diagnosis or treatment for age-related macular degeneration or cataracts.  
 The item or service you asked the Plan to waive the deductible for falls within the Vision Care benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 in- and 
out-of-network deductible which applies to outpatient physician services provided by an ophthalmologist or 
optometrist for the diagnosis or treatment of diseases and injuries of the eye, including diagnosis or treatment 
for age-related macular degeneration or cataracts. This cost sharing is a contractual obligation that had not been 
met at the time a medical eye exam was received on November 5, 2021. Therefore, we decided that the Plan 
does not have to waive the deductible for a medical eye exam provided on November 5, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in a skilled nursing facility 
with physical and occupational therapy. 
 
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. 
 The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a femur 
fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 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. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0394T-Q6 billed for date of service 
September 22, 2022. 
 
You asked the Plan to pay for procedure code 0394T-Q6. You say that you have provided medical records to 
support the billing of this code. The Plan denied your request. The Plan says payment for code 0394T-Q6 is 
bundled into payment for code 77401-Q6. 
 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 
0394T-Q6 is a column II code to column I code 77401-Q6. 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 0394T-Q6 billed for date of 
service September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Otto Bock C-Brace system. 
 
You asked the Plan to pre-approve the Otto Bock C-Brace system. You say that you would like reconsideration 
because the requested orthosis is medically necessary. The Plan denied your request. The Plan says this device 
is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Otto Bock C-Brace system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found an exhaustive review of the current, peer-reviewed medical literature does 
not provide sufficient evidence to show that the Otto Bock C-Brace system is both safe and effective in the 
context of lower extremity polyneuropathy (both sensation and muscle nerve loss) - at least two well-designed, 
peer-reviewed studies would need to show that the device is both safe and effective in patients. The peer-
reviewed literature review also shows this device to be investigational. 
 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 Otto Bock C-Brace system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Otto Bock C-Brace system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient hospital care beyond March 16, 
2022. 
 
You asked the Plan to pre-approve continued inpatient hospital care. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that you have exhausted this benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient hospital care is covered for up to 90 
days per benefit period with an additional 60 lifetime reserve days available. 
 
You began receiving inpatient services on July 23, 2021. You have not gone without inpatient or SNF care for 
more than 60 days and have used up all available hospital days plus the 60 lifetime reserve days. Although 
continued inpatient care may be appropriate, the benefit for these services has been exhausted for this benefit 
period. Therefore, we decided that the Plan does not have to pre-approve continued inpatient hospital care 
beyond March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from January 20, 2021, to 
January 29, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
 You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not 
supported as the principal diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical 
record. The Plan argues that DRG 193 is more appropriate in this case. 
 
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. DRG 871 requires a principal diagnosis of sepsis, organism 
unspecified (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 inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. 
Our physician reviewer found the enrollee with a past medical history of hypertension and chronic obstructive 
pulmonary disease (COPD), presented to the emergency room with complaints of shortness of breath, 
productive cough, fever, and malaise. Chest x-ray revealed some haziness may be due to pneumonia. 
Emergency department noted the enrollee had COPD exacerbation, acute on chronic hypoxic respiratory 
failure, hypertensive emergency, and sepsis probably due to gram positive organisms. There was no clinical or 
laboratory evidence of sepsis. The review has determined that the medical records did not support the billing of 
principal diagnosis sepsis, unspecified organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from January 20, 2021, to January 29, 
2021, as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on 
June 28, 2021. 
 You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says payment for this service is included in the 
payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by 
ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic 
services not available at the facility where the patient is an inpatient is covered by the prospective payment rate 
to the hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the record indicates that the enrollee was 
registered inpatient on the billed date of service. Payment for the ambulance services is included in the 
payment to the facility and is the responsibility of the facility to any outside vendor. Therefore, we decided that 
the Plan does not have to pay for the ambulance services (A0428 and A0425) provided on June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron. 
 
You asked the Plan to pre-approve Lupron. The Plan denied your request. The Plan says the enrollee does not 
have any contraindications to the preferred product. 
 
 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 Lupron. Our physician reviewer found 
that in this case, the record indicates that the enrollee has prostate cancer. The requested medication is a new 
start. The Plan requires a trial of Eligard before they will approve the requested drug. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Lupron.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that the requested Stelara is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Enbrel, Humira, or Skyrizi 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 Stelara. 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 Psoriasis vulgaris. 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 Stelara have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stelara.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on December 13, 2021. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says the benefit is 
covered once every 12 months and the patient exhausted this benefit. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services one per year. 
 
We looked at the file and the Plan's rules. The file says you received an eye refraction on April 6, 2021, and 
you have exhausted the benefit. Therefore, we decided that the Plan does not have to pay for an eye refraction 
provided on December 13, 2021.