Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 2, 2022. 
 
You asked the Plan to pay for the home health services. You say that the date of service is correct. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
 
 We looked at the file and the Medicare rules. We find that both the NOA and claim at issue does not have a 
from date of the first period of continuing care in 2022 as required. Based on this information, we find that the 
Medicare rules for payment have not been met. Therefore, we decided that the Plan does not have to pay for the 
home health services provided from February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve human cellular tissue product (HCT/PE) injection with 
placental tissue treatment (Interfyl). 
 
You asked the Plan to pre-approve human cellular tissue product (HCT/PE) injection with placental tissue 
treatment (Interfyl). You say that human cellular tissue product (HCT/PE) injection with placental tissue 
treatment (Interfyl) is medically necessary. The Plan denied your request. The Plan says human cellular tissue 
product (HCT/PE) injection with placental tissue treatment (Interfyl) is unproven and 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 human cellular tissue product 
(HCT/PE) injection with placental tissue treatment (Interfyl). Our reviewer says that the requested human 
cellular tissue product (HCT/PE) injection with placental tissue treatment (Interfyl) is not considered medically 
reasonable and necessary. Our physician reviewer found that this particular product has not yet been supported 
by high-quality evidence to show safety and effectiveness for general use in a similar clinical situation as this 
enrollee. Therefore, without more supportive studies for Interfyl, this request for such will be considered not 
medically 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 human cellular tissue product (HCT/PE) injection with placental tissue 
treatment (Interfyl) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
human cellular tissue product (HCT/PE) injection with placental tissue treatment (Interfyl).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
August 15, 2022, through August 18, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient psychiatric hospital care provided 
was medically necessary for the enrollee. The Plan denied your request. The Plan says the acute inpatient 
psychiatric hospital care provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for the acute inpatient psychiatric hospitalization on August 15, 2022 with 
Schizoaffective Disorder Bipolar Type. Based upon review the records provided, it was not expected this 
enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others. He 
had auditory no visual hallucinations, delusions and was not showing any behavioral issues. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care as he did not have dangerousness to self or others, nor did he have perceptual 
disturbance including delusions. The health plans denial of inpatient psychiatric services appears appropriate. 
This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or 
others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not 
appear that the services were reasonably expected to improve the enrollees condition or were for the purpose 
of a diagnosis. Based upon the review of the records provided, this enrollee does not meet criteria for coverage 
of the acute inpatient mental health treatment provided.  
 
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 acute inpatient psychiatric hospital care provided from August 15, 2022, through August 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0438 billed for date of service June 16, 
2022. 
 
You asked the Plan to pay for procedure code G0438. You say that the claim was submitted two times in error. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code G0438 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code G0438 billed for date of 
service June 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided during an outpatient facility 
stay from July 12, 2022, to July 14, 2022. 
 
You asked the Plan to pay for self-administered drugs. The Plan denied your request. The Plan says self-
administered drugs given to the member while they are in outpatient basis at a facility and are apt to be covered 
under the members Part D coverage whether that coverage is with the Plan or another company/plan. 
 
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 pay for self-administered drugs provided 
during an outpatient facility stay from July 12, 2022, to July 14, 2022.   
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the enrollee has 
obesity-hypoventilation syndrome. The enrollee was hospitalized for a febrile illness in October, and arterial 
blood gas (ABG) tests showed mild CO2 retention. There is no diagnosis of severe chronic obstructive 
pulmonary disease (COPD), thoracic restrictive disease, or neuromuscular disease. The enrollee may benefit from BiPAP during sleep; this has not been shown to fail as an outpatient when medically stable. Medicare 
does not cover a home ventilator in the treatment of obesity-hypoventilation syndrome. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 17, 2022, to 
April 23, 2022, 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 these 
services were reported appropriately and are supported as billed. The Plan denied your request. The Plan says 
the DRG submitted on this claim is not supported in the medical record. 
 
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 streptococcal sepsis (A40.8) and severe sepsis 
without septic shock (R65.20). 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 these diagnoses are not supported for 
billing in this case. Our physician reviewer found that there was no clinical or laboratory evidence of sepsis in 
this case. The review has determined that the medical records did not support the billing of streptococcal sepsis 
(A40.8) and severe sepsis without septic shock (R65.20).  
 
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 April 17, 2022, to April 23, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim System implant. 
 
You asked the Plan to pre-approve a Barostim System implant. You say that the requested Barostim System 
implant is medically necessary. The Plan denied your request. The Plan says the requested Barostim System 
implant 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 a Barostim System implant. Our 
reviewer says that the requested Barostim System implant is not medically necessary. Our physician reviewer 
found Baroreflex stimulation devices have been considered potential alternative treatments for resistant 
hypertension and heart failure. The Barostim Neo system is an electronic pulse generator implanted underneath 
the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers 
electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In 
August 2019 the FDA approved the system for use in patients with refractory heart failure who remain 
symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have an ejection 
fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved cardiac 
levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the 
Barostim Neo system would not be considered medically reasonable and necessary in this enrollees clinical 
management. 
 
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 Barostim System implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Barostim System implant.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Atezolizumab. 
 
You asked the Plan to pre-approve Atezolizumab. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Atezolizumab. Our reviewer says that 
Atezolizumab is not reasonable and necessary for the enrollee. Our physician reviewer found the FDA has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. Our reviewer found that no literature from Medicare approved cancer journals were submitted for 
review. The elements of the coverage criteria are not satisfied. Our physician reviewer also found that 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 Atezolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Atezolizumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service August 24, 
2022. 
 You asked the Plan to pay for procedure code 99291. You say that the claim should not be denied for lack of 
records. The Plan denied your request. The Plan says payment for code 99291 is bundled into payment for code 
36556. 
 
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 99291 is a column II code to column I code 36556. 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 99291 
billed for date of service August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor addition to a lower extremity 
prosthesis. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is non-coverable. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records support that you are a K2 ambulator. There is no evidence of variable cadence or 
vocational, exercise, or advanced therapy 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a microprocessor addition to a lower extremity prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for continued coverage of a home mechanical ventilator that is not 
being used by the enrollee is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that there is no 
documentation of chronic C02 retention on arterial blood gas study done while stable and awake. If you do 
have chronic C02 retention, you may benefit from bilateral positive airway pressure (BiPAP) with average 
volume-assured pressure support (AVAPS) and a backup rate. However, Medicare does not cover a home 
ventilator when used as BiPAP.  
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the enrollee has 
chronic obstructive pulmonary disease (COPD), although there are no pulmonary function tests.  The arterial 
blood gas (ABG) test while stable as an outpatient showed mild CO2 retention. This may be due to a 
combination of COPD, Obesity hypoventilation syndrome (OHS)/Obstructive sleep apnea (OSA), and opioid use. The enrollee may benefit from BiPAP with AVAPS during sleep. Medicare does not cover a home 
ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 is a column II code to column I code 70496. 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 70450 
billed for date of service August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service June 29, 
2021. 
 
You asked the Plan to pay for procedure code 99213. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99213 is bundled into payment for code 77263. 
 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 99213 
is a column II code to column I code 77263. 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 99213 billed for date of service June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic services (37253, 75625, 75774, 76937, 99152, 
J1200, J2250, J2270, J2405, J2930, J3010) billed for date of service August 11, 2022. 
 
You asked the Plan to pay for diagnostic services. You say that the services at issue have been billed correctly. 
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 September 15, 2022. 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 diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic services (37253, 75625, 75774, 
76937, 99152, J1200, J2250, J2270, J2405, J2930, J3010) billed for date of service August 11, 2022.