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

 
We decided that the Plan does not have to pre-approve four (4) home health physical therapy visits (G0151 x 
4). 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
deconditioned but functioning at home. The enrollee's homebound status is not specified. The enrollee would 
benefit from a home exercise program. Endurance and strength training require repetitive exercise not 
continued input from a skilled therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four (4) home health physical therapy visits (G0151 x 4).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve Aranesp. You say that the ferritin is 108.5 and iron saturation is 20%. You 
also say that there is a probability of hospitalization due to decreased hemoglobin. The Plan denied your 
request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 Aranesp. Our reviewer says that the 
enrollee does not meet the coverage criteria for Aranesp. Our physician reviewer found the enrollee has not 
tried and failed the required drugs. Our reviewer also found that there is no documentation provided indicating 
that the Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the IRF services you are requesting do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you have used Euflexxa in the past. The Plan denied 
your request. The Plan says the Plan requires a trial of Monovisc, Orthovisc, Synvisc, or Synvisc-One before it 
will approve Euflexxa. 
 
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 
enrollee does not meet criteria for a step therapy exception for Euflexxa. Our physician reviewer found the 
enrollee's condition does not represent a medically-accepted indication for the drug. The enrollee has not tried 
and failed the Plan's preferred drugs of Monovisc, Orthovisc, Synvisc, or Synvisc-One. The record does not 
show that these drugs would likely be less effective and/or have adverse effects for the enrollee. 
 
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 use of Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2067) provided on October 24, 
2022. 
 
You asked the Plan to pay for opioid treatment services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. 
 
We looked at the file and Medicare rules. This service was billed by an individual provider and not by an 
approved treatment facility. Based on this information, we decided that Medicare rules for coverage of opioid 
treatment services have not been met. Therefore, we decided that the Plan does not have to pay for opioid 
treatment services (G2067) provided on October 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter placement of intravascular stent(s) 
(37215). 
 
You asked the Plan to pre-approve a transcatheter placement of intravascular stent(s). You say that the enrollee 
is at high risk for open carotid endarterectomy due to previous stroke and other health risk factors. The Plan 
denied your request. The Plan says this request is not medically necessary because the records show the 
enrollee does not have symptomatic carotid artery disease, or that the enrollee has stenosis of greater than 80% 
on the side of requested treatment. 
 
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 transcatheter placement of 
intravascular stent(s). Our reviewer says that the documentation does not meet coverage criteria and does not 
support the medical necessity of the procedure in question. Our physician reviewer found the enrollee is status 
post multiple endovascular procedures, include a left transcarotid artery revascularization (TCAR) that 
followed a left hemispheric stroke. The computed tomography (CT) scan report describes a 40% to 50% 
stenosis of the right internal carotid artery. There do not appear to be any symptoms associated with the right 
carotid territory documented. The medical record does not include a rational for recommending the right 
TCAR. Currently the objective data is that of an asymptomatic, less than 50% stenosis of the fifth internal 
carotid artery. The requested service is not 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 a transcatheter placement of intravascular stent(s) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a transcatheter placement of intravascular stent(s) 
(37215).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 27, 2022, billed 
with codes 81226, 81240, 81241, 81306, 81328, 81335, 81225, 81227, 81231, 81232 and 81291. 
 You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 27, 2022, billed with codes 81226, 81240, 81241, 81306, 81328, 81335, 81225, 81227, 81231, 
81232 and 81291.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on July 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 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 services. Our reviewer says that the use of code 99223 is 
not supported by the records provided. Our reviewer found that the provided records do not document an 
extensive number of diagnoses or management options, an extensive amount and complexity of data reviewed 
and high risk of complication. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99223) provided on July 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve robotic-assisted surgical navigation for a coronary 
artery bypass graft (CABG) procedure at the inpatient level of care. 
 
You asked the Plan to pre-approve robotic-assisted surgery. You say that this surgery is not elective. The Plan 
denied your request. The Plan says the clinical value and effectiveness of robotic-assisted surgery have not 
been demonstrated. 
 
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 robotic-assisted surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the clinical value and effectiveness of robotic-assisted CABG has not yet been 
established in controlled clinical studies. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of robotic-assisted surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve robotic-assisted surgical navigation for a coronary artery bypass graft (CABG) 
procedure at the inpatient level of care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services (33233, 33235, 80048, 85027, 85610, 
87070, 87102, 87205, 87210, J0690, J2001, J2250, J3010) provided on September 2, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered 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. 
 
Procedure codes 33233 and 33235 is identified in Addendum B by status indicator Q2 which is defined as a 
Q2-T-Packaged codes. OCE edit identified the packaged service procedure codes 33233 and 33235 as a 
device dependent code as indicated by the "1". Intensive procedure code that was reported without a device 
HCPCS code required for that procedure and under the OPPS separate payment is made for packaged services 
when no status indicator "Q2" services have been reported on the same claim. Additionally, all the procedure 
codes 80048, 85027, 85610, 87070, 87102, 87205, 87210, J0690, J2001, J2250 and J3010 billed on the claim 
are not valid device codes as indicated by the 0. All other remaining lines available on the claim are denied 
as 0992 - PLEASE CORRECT OCE EDIT ERROR ON OTHER CLAIM LINE" due to RTP disposition 
available for OCE edit 92. Therefore, we decided that the Plan does not have to pay for the outpatient services 
(33233, 33235, 80048, 85027, 85610, 87070, 87102, 87205, 87210, J0690, J2001, J2250, J3010) provided on 
September 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve septoplasty or submucous resection, with or without 
cartilage scoring (30520) nasal/sinus endoscopy, surgical; with ethmoidectomy (31254) nasal/sinus endoscopy, 
surgical; with dilation of maxillary sinus ostium (31295). 
 
You asked the Plan to pre-approve the sinus surgery. You say that you are requesting an appeal for the denied 
authorization. The Plan denied your request. The Plan says this request does not meet the medically necessary 
criteria. 
 
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 sinus surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of chronic pansinusitis, as well as septal deviation and inferior turbinate hypertrophy. The proposed sinus procedures are generally reserved for those patients who 
have failed appropriate medical therapy. There is insufficient documentation of inadequate response to 
maximal medical therapy. 
 
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 sinus surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve septoplasty or submucous resection, with or without cartilage scoring (30520) 
nasal/sinus endoscopy, surgical; with ethmoidectomy (31254) nasal/sinus endoscopy, surgical; with dilation of 
maxillary sinus ostium (31295).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63042 and 63044 billed for date of service 
October 11, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
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 63042 is laminotomy (hemilaminectomy), with 
decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated 
intervertebral disc, re-exploration, single interspace; lumbar. The definition of code 63044 is laminotomy 
(hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or 
excision of herniated intervertebral disc, re-exploration, single interspace; each additional lumbar interspace 
(List separately in addition to code for primary procedure).  We find that CPT codes 63042 and 63044 is not supported in the medical record. Specifically, the records do 
not show that a laminotomy was provided. There is a more suitable code available to describe the laminectomy 
services provided. 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 procedure codes 63042 and 
63044 billed for date of service October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95912) provided on October 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95912 is "Nerve conduction studies; 11-12 studies". 
 
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 services. Our reviewer says that the use of code 95912 is 
not supported by the records provided. Our reviewer found that according to CPT assistant, nerve conduction 
studies are performed by placing electrodes directly over the specific nerve or muscle to be tested. The documentation submitted does not support that this was performed and produced for 11-12 studies. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (95912) provided on October 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint (27096). 
 
You asked the Plan to pre-approve an injection procedure for sacroiliac joint. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service 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 an injection procedure for sacroiliac 
joint. Our reviewer says that the requested service is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the physical exam does not support the diagnosis of Sacroiliitis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an injection procedure for sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an injection procedure for sacroiliac joint (27096).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on December 22, 2022. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says the medical records do not show screening 
test results which are positive or inconsistent with prescription medications, dosing schedules, or history and 
expected results. 
 The Plan follows Medicare rules. Medicare rules say that this testing is covered when the results of the screen 
are presumptively positive or the results of the screen are negative, and this negative finding is inconsistent 
with the enrollees medical history. 
 
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 definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that there 
is no documentation of use of drugs of abuse, diversion or non-compliance. There is no screening qualitative 
testing. The request does not meet LCD criteria for ordering definitive UDT.  It was not 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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on December 22, 2022.