Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
information shows the enrollee's medical needs are being met at the current medical center. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee opted for palliative care and no surgery after discussion with treating 
physicians. The enrollee appears to be more stable now and only requiring short term additional acute care 
services that can be safely provided at the current facility until more stable to a transfer to a lower level of care 
for continued palliative care. The enrollee does not require services at the LTACH that are not already available 
at the current facility. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service May 26, 
2022. 
 
You asked the Plan to pay for procedure code S9338. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on May 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a nursing facility visit. You say that the facility has a contract with providers for 
the residents, who often need urgent care. Therefore, it is not always possible to get preauthorization, and this 
patient is disabled and unable to make it to an in-network provider. The Plan denied your request. The Plan 
says there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-
network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a nursing facility visit provided on May 31, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Feraheme. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia. The documentation does not support that the enrollee has tried 
and failed Infed (iron dextran). The documentation does not support that Infed would likely be less effective 
and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided on May 9, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmology services. You say that the patient provided you with incorrect 
insurance information. The Plan denied your request. The Plan says unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. It is the provider's obligation to confirm insurance coverage prior to rendering services. Therefore, we decided that the Plan does 
not have to pay for ophthalmology services provided on May 9, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device. 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that this device is medically necessary. 
The patient suffers from shortness of breath and fatigue and has failed other therapies. The Plan denied your 
request. The Plan says the Barostim Neo device is considered experimental/investigational for the patient's 
condition. 
 
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 Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. 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 Food and Drug Administration (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 patients 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 the Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you provided medical care as an out-of-network 
provider in good faith. The Plan denied your request. The Plan says the enrollee must receive care from a 
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on June 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 15, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this is the correct code and payable with the 
modifier used. You say that the medical records should be reviewed, and the claim processed to pay. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closed treatment of distal fibular fracture (lateral malleolus) 
(27786) provided February 28, 2022. 
 
You asked the Plan to pay for the hospital visit. You say that please see requested notes for review and 
processing. The Plan denied your request. The Plan says duplicate procedure/payment. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the hospital visit have been met. 
additional information was needed to determine how the enrollee came to the servicing provider or whether the 
services were medically necessary. The Plan made multiple attempts to obtain the additional records from the 
provider without success. Therefore, we decided that the Plan does not have to pay for closed treatment of 
distal fibular fracture (lateral malleolus) (27786) provided February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
July 9, 2022, to July 13, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot get out of bed 
to take care of yourself. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for in-network inpatient hospital care for days 1 to 5; $0 copayment per day, days 6 to 90. 
 
You have been asked to pay $975 for inpatient hospital care ($325/day x 3 days = $975). This item/service falls 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital care provided from July 9, 2022, to July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on February 22, 2022, February 28, 
2022, and March 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that it was medically necessary to treat the enrollee and 
you like the claims to be reprocessed for payment. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visits provided on February 22, 2022, 
February 28, 2022, and March 28, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI), of 
the brain (including brain stem); without contrast material, followed by contrast material(s) and further 
sequences (70553) provided on June 14, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the 
service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for mammography and ultrasounds. Additionally, you must pay a $150 copayment for all other 
diagnostic and nuclear medicine radiological services.     
You have been asked to pay a $150 copayment for the diagnostic radiological service provided. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the magnetic resonance imaging (MRI), of the brain (including brain 
stem); without contrast material, followed by contrast material(s) and further sequences (70553) provided on 
June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 23, 2022, to 
January 26, 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 the 
diagnosis of J96.01 (acute respiratory failure with hypoxia) is supported in the medical records, so the claim 
should be paid as billed. The Plan denied your request. The Plan says the diagnosis of J96.01 (acute respiratory 
failure with hypoxia) is not supported in the medical records, resulting in a lower DRG being paid. 
 
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 the diagnosis of J96.01 (acute respiratory failure 
with hypoxia). 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 diagnosis of J96.01 (acute respiratory failure 
with hypoxia) is not supported in the medical record. Our physician reviewer found the patient is a 78-year-old 
male who presented to the hospital with pneumonia with chronic obstructive pulmonary disease exacerbation 
requiring low dose oxygen (up to 3L via nc only), steroids, and antibiotics. He was noted to not be in acute 
distress, and pulmonary effort was normal. He refused bronchodilators. Arterial blood gases showed p02 55, 
pCO2 40, pH 7.423 on room air. It was not clear from the provided notes what the patient's baseline was. 
Following initial treatment, he no longer required any oxygen. Based on the presentation and progress notes, it 
was clear that the patient was not in any respiratory distress and didn't have significant enough hypoxia to meet 
the criteria for acute respiratory failure. Therefore, this diagnosis is not sufficiently supported in the notes.   
 
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 January 23, 2022, to January 26, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device. 
 
You asked the Plan to pre-approve the MyoPro orthotic device. The Plan denied your request. The Plan says 
this 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 MyoPro orthotic device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the requested robotic orthosis is not proven to be more beneficial for 
treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard 
therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced 
movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested 
device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or  to improve the 
functioning of a malformed body member. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MyoPro orthotic device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fractional laser therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a large body of literature evaluating functional laser treatment which primarily 
addressed cosmetic outcomes and not functional outcomes. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has a history of partial thickness burn cicatrix with 
itching and pain. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, 
of the requested service. The elements of the coverage criteria are not satisfied. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve fractional laser therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphometric analysis services coded 88360 provided on 
April 29, 2022. 
 
You asked the Plan to pay for the morphometric analysis services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88360 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 1. The claim was billed with a place of service 22 (on campus-outpatient 
hospital). Payment is not made under the physician fee schedule for technical component services furnished in 
institutional settings where the technical component service is bundled into the facility payment. The claim is 
not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
morphometric analysis services have not been met. Therefore, we decided that the Plan does not have to pay 
for the morphometric analysis services coded 88360 provided on April 29, 2022.