Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that you 
meet the Medicare criteria for SNF care. Our physician reviewer found you do not have documented skilled 
nursing needs. You do have documented skilled therapy needs. A period of daily skilled services is reasonable 
to establish a maintenance program and to prevent deterioration of your condition. 
 
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 skilled nursing 
facility (SNF) care.  
 
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: 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 the requested 
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 the requested home ventilator. Our physician reviewer found a home 
ventilator is not medically necessary. This enrollee has a diagnosis of chronic obstructive pulmonary disease 
(COPD).  He was hospitalized in January after a fall and chest trauma. The progress notes describe CO2 
retention on admission, but no arterial blood gas analysis (ABG) results are provided. The enrollee improved with overnight bipap. There is no documentation of chronic CO2 retention.  Medicare 
does not cover a home ventilator when used as bipap. Some bipap devices can provide the Average volume-
assured pressure support (AVAPS) mode of support. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care discharge day management (99217) 
provided on August 12, 2021. 
  You asked the Plan to pay for the observation care discharge day management (99217). The Plan denied your 
request. The Plan says the procedure code was not correct for the service or date of service 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. 
 
In this case, the CPT Code Manual definition of code 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]). 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, there is no documentation to 
support that an initial or subsequent observation service has been billed. Based on this information, we decided 
that Medicare rules for coverage of the observation care discharge day management (99217) have not been met. 
Therefore, we decided that the Plan does not have to pay for the observation care discharge day management 
(99217) provided on August 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81240, 81241). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested services are necessary due to 
clotting. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that this testing is non-covered except for pregnant 
patients. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve genetic testing (81240, 81241).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve antibiotic infusion services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve antibiotic infusions. You say that the enrollee is at high risk if not treated 
promptly and chose to be treated by this provider. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee 
can receive infusions from an in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
antibiotic infusion services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says criteria 
for admission to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that long term acute care hospital (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 there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. Our reviewer found that the enrollee can remain at the 
current ACH until such time no acute services are required.  Our physician reviewer also found that the 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. 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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on April 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71045) provided August 31, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were 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, we have confirmed that code 71045 
is a column II code to column I code 71046. 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 radiology services (71045) provided August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine foot care provided on August 11, 2021. 
 
You asked the Plan to pay for the routine foot care. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the routine foot care is not covered for your 
diagnosis. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
foot care provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectometry (83789) provided on July 12, 2021. 
 You asked the Plan to pay for the mass spectometry. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 83789 and 
G0480. 
 
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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
 
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 mass spectometry. Our reviewer says that CPT code 
83799 does not meet criteria for billing or reimbursement consideration. Our reviewer found specimen validity 
testing is not separately reported when performed as part of drug testing. 
 
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 mass spectometry have not been met. Therefore, we decided that the Plan 
does not have to pay for the mass spectometry (83789) provided on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that conservative methods of treatment have not 
sufficiently relieved the member of their back pain. The Plan denied your request. The Plan says that the 
enrollee does not have an acute or subacute compression fracture. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty can be covered if Medicare criteria 
has been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident if the enrollee has ever attended the prescribed physical therapy and if there was 
any benefit. There is limited published, large-scale, long-term peer-reviewed literature that shows this request 
to be an effective and/or safe treatment for the noted pathology. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endoscopy (43235) provided September 17, 2021. 
 
You asked the Plan to pay for the endoscopy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is 
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 CPT code. In this case, we have confirmed that code 43235 
is a column II code to column I code 43238. 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 an endoscopy (43235) provided September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full thickness graft (15240) provided on September 1, 
2021. 
 
You asked the Plan to pay for the full thickness graft (15240). The Plan denied your request. The Plan says the 
documentation does not support CPT code 15240. 
 
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 15240 is full thickness graft, free, including direct closure 
of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less. 
 
 
  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 full thickness graft (15240). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report does not include documentation of graft size to confirm this procedure code. 
 
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 full thickness graft (15240) have not been met. Therefore, we decided that 
the Plan does not have to pay for the full thickness graft (15240) provided on September 1, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc (J7320). 
 
You asked the Plan to pre-approve Genvisc. You say that the enrollee's knee x-ray shows degeneration which is 
why left knee Genvisc injections have been ordered for further management. The Plan denied your request. The 
Plan says the enrollee has not tried any of the preferred agents previously. The Plan also says that a rationale is 
not provided for use of the non-preferred product for safety or efficacy that is supported by the medical record. 
 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 Genvisc. Our reviewer says that 
Genvisc (J7320) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
provided documentation did not show that the enrollee has tried and failed Orthovisc, Synvisc, or Synvisc One, 
which would not be clinically less effective or cause more side effects than the requested Genvisc as the 
evidence shows they are all clinically equivalent. Our reviewer also found that there was no report of 
contraindication to one of these alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc (J7320).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The 
Plan says that the enrollee can safely receive the services needed in other settings. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical management of subdural hematoma, respiratory failure and bacteremia. The 
enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical arthroscopy of the shoulder with limited 
debridement (29822) provided on August 19, 2021. 
 
You asked the Plan to pay for a surgical arthroscopy of the shoulder with limited debridement. You say that 
you have provided medical records to support the billed service. The Plan denied your request. The Plan says 
the service at issue is inclusive to another billed code. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 a surgical arthroscopy of the shoulder with 
limited debridement Our reviewer says that the billed code does not meet criteria for reimbursement. Our 
physician reviewer found that the operative report documents a limited debridement; however, per Medicare 
guidelines a limited debridement is inclusive to shoulder arthroscopy with rotator cuff repair when performed 
at the same session.  
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 surgical arthroscopy of the shoulder with limited debridement have not been 
met. Therefore, we decided that the Plan does not have to pay for a surgical arthroscopy of the shoulder with 
limited debridement (29822) provided on August 19, 2021.