Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found bone marrow aspirate is considered 
experimental in nature. More research is needed to show its safety and efficacy. The services are therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 28, 2022 to February 3, 2022. 
 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a decision was not made in the 60-day 
timeframe. 
 
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 DRG 919. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that based on the provided documentation, the patient did not have sufficient evidence of sepsis being present 
as there was not a SOFA of 2 points to meet Sepsis 3 criteria. Organ function appeared to be stable in the 
setting of the infection. Kidney function was worsened initially, however, it was resolved with fluid 
administration suggesting it was not related to sepsis and also did not meet criteria for acute renal failure as the 
Cr did not increase by 0.3 as required. Therefore, records do not support the diagnoses of sepsis or acute kidney 
failure for this stay, and therefore, the DRG 921 would be more appropriate for this hospital stay.   
 
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 to the enrollee from January 28, 2022 to February 3, 2022.
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 the services are medically necessary. You say that 
the enrollee is highly motivated to participate in intensive rehab. The Plan denied your request. The Plan says 
criteria for admission to the IRF have not been met. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that per the denial, the patient had this service 
(D5120) already done in the pre-determined time frame when in fact it was code (D5422). You also say that 
these are two separate defining codes. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 26, 2021, with a 
partial mandibular denture (D5214). Therefore, we decided that the Plan does not have to pre-approve a 
complete mandibular denture (D5120).
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 the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee's needs can be met at a lower level of care such as skilled nursing facility (SNF), home with home 
health services or home with outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that Ilumya is medically necessary. The Plan denied your 
request. The Plan says a trial of Remicade, Inflectra or infliximab, and Stelara is required before alternatives 
can be considered. 
 
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 Ilumya. Our reviewer says that Ilumya 
is not medically necessary. Our physician reviewer found the records do not show a trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee received care for acute respiratory 
failure and cardiogenic shock. The Plan denied your request. The Plan says the enrollee does not have a 
medical condition so complex that they need frequent monitoring by a doctor on an inpatient basis in an IRF. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the enrollee may need skilled therapy with ongoing safety concerns and a potential for functional 
improvement, the documentation doesnt support that they would meet criteria for admission to an acute 
inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an 
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain her functional status.  The enrollee can receive further services at a lower 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 the IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided from January 12, 2022, 
through May 18, 2022, by a licensed professional counselor. 
 
You asked the Plan to pay for the mental health services. You say that these services should be reimbursed and 
approved for payment. The Plan denied your request. The Plan says the provider type in question is not eligible 
to enroll in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is on the list 
of individuals who are not eligible to enroll in Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mental health services have not been met. Specifically, the provider in question is not eligible 
to receive payment from Medicare. Therefore, we decided that the Plan does not have to pay for the mental 
health services provided from January 12, 2022, through May 18, 2022, by a licensed professional counselor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on July 25, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you are appealing the denied claim. The Plan 
denied your request. The Plan says the claim was reprocessed correctly. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays a $100 
maximum allowance toward the cost of a hearing aid(s) every year. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the claim was reprocessed, and the Plan paid $100 
towards the hearing aids. Therefore, we decided that the Plan does not have to pay for the hearing aids provided 
on July 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination of the chest provided on 
March 13, 2022. 
 
You asked the Plan to pay for the radiologic examination of the chest. The Plan denied your request. The Plan 
says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated 
to the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a radiologic examination of the chest provided on 
March 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 14, 2022, to 
February 12, 2022. 
 
You asked the Plan to pay for the home health 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 providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that the denied claim was submitted 
with an admission date of December 15, 2021, which does not match the admission date on the NOA. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from January 
14, 2022, to February 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment provided on May 27, 2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that you thought this equipment would be 
reimbursed at the out-of-network rate. The Plan denied your request. The Plan says payment cannot be made to 
a provider not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the oxygen equipment provided on May 
27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the onabotulinumtoxina (Botox) (J0585 
x 2), and chemodenervation of muscles (64615) provided on May 6, 2022. 
 
You asked the Plan to pay an additional amount for the drugs. You say that these services have been paid in 
full in the past. You say that this one has an extra charge. You also say that additional payment should be made 
on this bill. 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 20% 
coinsurance for Medicare Part B Prescription Drugs.  
 
You have been asked to pay a 20% coinsurance for the drugs. This service falls within the Medicare Part B 
Prescription Drugs 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 pay an additional amount for the 
onabotulinumtoxina (Botox) (J0585 x 2), and chemodenervation of muscles (64615) provided on May 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is considered medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
requested procedure is considered experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 74-year-old male being treated for spondylosis without 
myelopathy or radiculopathy of the lumbar region. He was noted with low back pain that began over 6 years 
ago. The pain is rated at a 7/10. However, formal diagnostic testing of the lumbar spine was not provided for 
review. There were no examinations provided for review.  
 
Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of 
the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as 
being medically necessary and/or reasonable at this time. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested Intracept intraosseous basivertebral nerve ablation at L3, L4, L5, and S1 vertebral bodies, in this 
case, is not medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wall rail. 
 
You asked the Plan to pre-approve a wall rail. You say that this is necessary for your condition. The Plan 
denied your request. The Plan says this is not covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wall rail.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99235 billed for date of service August 25, 2022. 
 
You asked the Plan to pay for code 99235. You say that payment for this code was denied in error. The Plan 
denied your request. The Plan says code 99235 was billed incorrectly. 
 
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 99235 is Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and medical decision 
making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified 
healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patients 
and/or familys needs. Usually the presenting problem(s) requiring admission are of moderate severity. 
Typically, 50 minutes are spent at the bedside and on the patients hospital floor or unit. 
 
We find that CPT code 99235 is not supported in the medical record. Specifically, code 99235 is only to be 
used when admission and discharge occur on the same date.  In this case, the records show that the patient was admitted at 2:21pm on August 24, 2022.  You billed code 99235 for date of service August 25, 2022.  This 
means that admission and discharge did not occur on the same date. A different code should be used in this 
scenario. Based on this information, we decided that Medicare rules for coverage of code 99235 have not been 
met. Therefore, we decided that the Plan does not have to pay for code 99235 billed for date of service August 
25, 2022.