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 June 27, 
2022, to July 26, 2022. 
 You asked the Plan to pay for SNF care. You say that services which the claimant required and received during 
the period in question are coverable. The Plan denied your request. The Plan says the member did not have a 
daily skilled nurse or therapist need. 
 
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 based on the documentation provided, the enrollee no longer qualified for SNF 
coverage after June 26, 2022. The enrollee did not have documented skilled nursing needs. The enrollee did not 
have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs could, as a practical 
matter, be provided 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 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 June 27, 2022, to July 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 27, 2022, 
to October 24, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim complies with billing guidelines. The 
Plan denied your request. The Plan says the rules for payment have 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 code. 
 
We looked at the file and the rules. The claim submitted does not include a value code as required. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from September 
27, 2022, to October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis described by code L1852 and suspension 
sleeve rendered on December 9, 2022. 
 
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 the services were not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of unilateral 
primary osteoarthritis of the left knee. The office note dated November 7, 2022 is a one-month follow up on 
blood pressure during which the enrollee denied painful joints. She has not had a surgical procedure on the 
knee. There is no documentation of knee instability. The criteria for coverage are not met and the knee orthosis 
with suspension sleeve were not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee orthosis described by code L1852 and suspension sleeve rendered on December 9, 
2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is 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 radiofrequency ablation. Our reviewer 
says that the documentation does support that the requested services are medically reasonable and necessary. 
Our physician reviewer found the enrollee has chronic low back pain. The enrollee's physical exam and 
imaging support the diagnosis of facet joint syndrome. The enrollee had two diagnostic MBBs bilaterally at L4-
L5 and L5-S1 which gave temporary 100% pain relief. The documentation shows that the enrollee meets all of 
the criteria of the LCD. Therefore, the enrollee meets criteria for the requested 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 radiofrequency ablation have been met. Therefore, we decided that the Plan has 
to pre-approve radiofrequency ablation (RFA).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the fluoroscopic guidance for needle placement (77002), and 
injection (20610) provided from May 2, 2022, to May 24, 2022. 
 
You asked the Plan to pre-approve the outpatient services. You say that these codes are billable. You say that 
they are not considered experimental. You also say that the services were medically necessary. The Plan denied 
your request. The Plan says that the services are experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the outpatient services. Our reviewer 
says that the fluoroscopic guidance and injection are considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation indicate that these services are part of the 
standard therapy for osteoarthritis. Therefore, the reviewer found that the services were medically reasonable 
and 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 outpatient services have been met. Therefore, we decided that the Plan has 
to pre-approve the fluoroscopic guidance for needle placement (77002), and injection (20610) provided from 
May 2, 2022, to May 24, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services provided on March 29, 2022. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that the procedure was postponed, canceled, or 
delayed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the specific denial rationale offered by the Plan is not supported. 
The rule cited to support the denial is not applicable to professional claims. In addition, the original claim was 
denied as duplicate, but no evidence was provided to prove that payment was ever made for the service. 
Therefore, we decided that the Plan has to pay for imaging services provided on March 29, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for April 29, 2022, to May 2, 
2022. 
 
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 99223 is not supported by 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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 these services. Our reviewer says that procedure code 99223 
is not supported by the medical records. Our reviewer found the submitted records do not support that the 
encounter required decision making of high complexity. The billing of code 99223 is not supported for the 
dates of service at issue. 
 
We looked at this coder'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 pay for procedure code 99223 billed for April 29, 2022, to May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on November 9, 
2022. 
 
You asked the Plan to pay for the initial hospital care. You say that you would like this claim to be 
reconsidered for payment. The Plan denied your request. The Plan says the billed services were 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 99223 is initial hospital 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, 70 minutes are spent at the bedside and on the patient's hospital 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 the initial hospital care. Our reviewer found the history is not 
comprehensive. The medical decision making is not of high complexity. Our reviewer found that as such, the 
billing of CPT 99223 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for the initial hospital care (99223) provided on November 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 9, 2022, to 
March 3, 2022. You asked the Plan to pay for the billed services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the NOA was not received timely. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 9, 2022. The NOA was not received by the Plan until May 11, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from February 9, 2022, to March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VivAer procedure. 
 
You asked the Plan to pre-approve a VivAer procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a VivAer procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical records and review of the current peer-reviewed medical literature 
do not document that the VivAer procedure has been shown in controlled studies in a CMS-approved medical 
journal to result in long term health benefits in enrollee with nasal valve collapse with turbinate hypertrophy and nasal septal deviation. 
 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VivAer procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable power wheelchair controller (E2377) 
with related electronic connections (E2311) and harness (E2313). 
 
You asked the Plan to pre-approve the expandable controller and related hardware. You say that the requested 
features should be approved. The Plan denied your request. The Plan says though the power wheelchair is 
approved, the expandable controller 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 the expandable controller and related 
hardware. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has adequate upper body strength to manage multiple 
power drive controls with the individual switches. Controlling these options through the main drive control exceeds what is necessary to meet the enrollee's 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 the expandable controller and related hardware have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable power wheelchair controller (E2377) with 
related electronic connections (E2311) and harness (E2313).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that without the continuation of skilled nursing this 
could seriously jeopardize their ability to regain maximum function. The Plan denied your request. The Plan 
says your request does not meet Medicare guidelines because you no longer require skilled services and the 
continuation of SNF is 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service August 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was rendered in an appropriate place of 
service. The Plan denied your request. The Plan says you billed these lab services with an incorrect Place of 
Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit claims with the correct 
POS code entered on the claim. Services rendered to a hospital outpatient should be billed POS code 22. 
Services rendered to an hospital inpatient should be billed with POS code 21.   
 
In this case, you billed the lab services at issue with POS code 22. However, records show that the patient was 
in an inpatient stay on the date of service in question.  As a result, the correct POS code for the lab services is 
21, not 22 as billed. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services billed for date of service August 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for infectious agent detection by nucleic acid (87624) provided on June 9, 
2022. 
 
You asked the Plan to pay for infectious agent detection by nucleic acid. You say that this service was 
medically necessary and was reported correctly. The Plan denied your request. The Plan says that according to 
Local Coverage Article (LCA) A58747, code 87624 is not covered for any given enrollee on the same date of 
service when it is either billed in combination with another code from groups 1-7 of the article for the same 
intended use, or when it is billed with another two codes from the same group for the same intended use. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no evidence to support that any other 
services, specifically at least one code from groups 1-7 of the mentioned LCA or two or more from group 8, 
were also billed for this enrollee on the same date of service. The single code in question is the only code on 
this claim, and no other claims were submitted as evidence to support the Plan's denial. In addition, the specific 
LCA cited by the Plan does not have jurisdiction over the state where these services were provided. Therefore, 
we decided that the Plan has to pay for infectious agent detection by nucleic acid (87624) provided on June 9, 
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: Step-Therapy
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
you have tried and failed the plan's preferred step one alternative. The record does not indicate that you have 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.