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

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
August 16, 2022. 
 
You asked the Plan to pay for the initial hospital care services coded 99223. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are 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 services coded 99223. Our reviewer 
says that the documentation does not support the code billed. Our reviewer found the enrollee was evaluated 
for nausea and diarrhea. The documentation does not support there was a comprehensive history. Therefore, 
code 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 services coded 99223 have not been met. Therefore, we 
decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on August 
16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that this is needed to evaluate the enrollee's behavior. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for this can. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan may be covered for enrollees with a 
recent diagnosis of dementia and cognitive decline who meet diagnostic criteria for both Alzheimers Disease 
and frontotemporal dementia. 
 
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 PET scan. Our reviewer says that the 
enrollee does not meet criteria for this scan. Our physician reviewer found the enrollee was noted to have 
memory problems. However, it was not clear from records that the enrollee met diagnostic criteria for either 
Alzheimers Disease or frontotemporal dementia (FTD). Furthermore, testing for other factors was ordered but 
such a work-up has not been completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post stabilization care provided on July 12, 2022, to July 19, 
2022. 
 
You asked the Plan to pay for post stabilization care. You say that the enrollee was not able to transfer due to a 
drug overdose. The Plan denied your request. The Plan says post stabilization was not necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our physician 
reviewer found There was no documentation provided necessitating post-stabilization care services after 
10:24am on 7/14/22. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post stabilization care provided on July 12, 2022, to July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99214) provided on November 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 We looked at the file and Medicare rules. Payment for the requested services (99214) is included in the global 
surgery payment for the procedure (33533) provided on August 8, 2022, which has a 90-day global period. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the services (99214) provided on November 3, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup for tooth number 19. 
 
You asked the Plan to pre-approve the dental services. You say that a core buildup for tooth number 19 is 
required for the crown to successfully bond. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup for tooth number 19.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says there is not a good rationale for IMRT versus other treatment plans. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is nothing in the record to suggest that a 3-dimensional plan would either not sufficiently 
treat the cancer or would result in unacceptable exposure to normal tissues. With palliative doses, it is not 
plausible that IMRT would yield a clinically meaningful benefit. No specific quantitative dosimetric rationale 
for IMRT is given, only a statement that IMRT is needed to reduce lung and esophageal dose/toxicity without 
showing a comparison that actually demonstrates this. There needs to be a dosimetric reduction in normal 
tissues to justify the need for IMRT. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) care from March 
25, 2023, forward. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot go home at this time and would not have 
the proper help or care needed to continue getting better. The Plan denied your request. The Plan says that the 
continuation of SNF services 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have not shown sustained progress at supervision level and has moved from 
moderate assist to minimal assist during an appropriate time-line. You continue to make material gains. You 
are making material gains within a predictable time-line. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve the continuation 
of skilled nursing facility (SNF) care from March 25, 2023, forward.  
 
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 physician services (99236) provided on March 15, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99236 is evaluation and management code for a patient 
that was admitted and discharged on the same date requires a comprehensive history, a comprehensive 
examination and medical decision making of high complexity. 
 
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 physician services. Our reviewer says that the 
documentation does not support the billed code. Our reviewer found the documented history in this case does 
not contain all required elements to meet criteria for a comprehensive history. The medical decision making in 
this case does not document a high risk of complications. 
 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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99236) provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223, 99232) provided on June 10, 2021 
to June 14, 2021. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of codes 99223 & 99232 are 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 and Subsequent 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 moderate level of medical decision making. 
 
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 physician services. Our reviewer says that the records do 
not support the codes billed. Our reviewer found the submitted records do not support the services billed. 
Additional records were requested by the health plan and were not received. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223, 99232) provided on June 10, 2021 to June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99215) provided on September 2, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99215 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is 
spent on the date of the encounter with date of service. 
 
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 physician services. Our reviewer says that the code billed 
is not supported in the records. Our reviewer found the submitted records did not support code 99215 being 
performed by servicing provider on this date of service. 
 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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99215) provided on September 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy for prostate cancer treatment. 
 
You asked the Plan to pre-approve radiation therapy for prostate cancer treatment. You say that radiation 
therapy for prostate cancer treatment is medically necessary. The Plan denied your request. The Plan says there 
is no current research showing that the member's type of cancer responds better to the requested type of 
treatment than the type of treatment we can approve, which is Intensity-Modulated Radiation Therapy (IMRT). 
 
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 radiation therapy for prostate cancer 
treatment. Our reviewer says that the requested radiation therapy for prostate cancer treatment is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that to date, there are no 
compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy for prostate cancer treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiation therapy for prostate cancer treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to you from May 3, 2022, to May 18, 
2022. 
 
You asked the Plan to pay for the services. You say that the provider is refusing to resubmit the claim. The Plan 
denied your request. The Plan says the claim must first be submitted to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided to you from May 3, 2022, to May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 04, 2021, 
through August 16, 2021, and billed with diagnosis code A41.9. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis code A41.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support primary diagnosis of A41.9. 
 
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 primary diagnosis code A41.9-Sepsis, unspecified 
organism. 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 documentation does not support the primary diagnosis of 
A41.9, sepsis. Our physician reviewer found the member complained of all over body pain, had a fever, was 
hyperglycemic, had leukocytosis, elevated procalcitonin, hyponatremia, and hyperkalemia with signs of 
infected food wound with osteomyelitis. However, Sepsis 3 criteria was not met. Therefore, diagnosis code 
A41.9-Sepsis, unspecified organism is not the appropriate primary diagnosis code.  
 
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 August 04, 2021, through August 16, 2021, and billed with 
diagnosis code A41.9.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injection services. 
 
You asked the Plan to pre-approve Orthovisc injection services. You say that the enrollee did not have relief 
with the Gel-One injection but has had Orthovisc in the past and it did provide relief. The Plan denied your 
request. The Plan says the guidelines for coverage 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 Orthovisc injection services. Our 
reviewer says that Orthovisc injection services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has right knee osteoarthritis and previously had steroid 
injections. The enrollee had bilateral Gel-One injections in February, but only had a day of pain relief. There is no published evidence that having failed one viscosupplement, that another medication is going to be effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Orthovisc injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. The Plan denied your request. The Plan says the coverage criteria 
are not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
requested CGM is not medically reasonable and necessary. Our physician reviewer found that the enrollee is 
not taking insulin, and thus does not meet the coverage criteria. 
 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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G6 continuous glucose monitor (CGM).