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

 
We decided that the Plan does not have to pay for inpatient hospital services provided from December 6, 2021, 
to December 12, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records make it clear that J96.01 met the criteria for secondary diagnosis reporting as this diagnosis led 
directly to the admission. You say that the claim should be reprocessed under DRG 193. The Plan denied your 
request. The Plan says payment of DRG 193 is not supported. 
 
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 secondary diagnosis code J96.01, defined as acute 
respiratory failure, not elsewhere classified Type 2 [with hypercapnia]. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the documentation does not support secondary diagnosis code J96.01 and payment at DRG 193. Our 
physician reviewer found that there was no clinical evidence of acute respiratory failure.  
 
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 from December 6, 2021, to December 12, 2021, at the DRG originally 
billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says Euflexxa is a non-
preferred product. The Plan also says that the enrollee does not have any stated contraindications to the 
preferred products. 
 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 the criteria for coverage for Euflexxa. Our physician reviewer found there is no 
indication that the enrollee has tried and failed the required drug(s). Our physician reviewer also found that 
there is no indication that the Plan's required drug(s) 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for chemotherapy administration, intravenous infusion technique; up to 1 
hour, single or initial substance/drug (96413), injection, pembrolizumab, 1 mg (J9271) and laboratory services 
provided on June 27, 2022. 
 
You asked the Plan to pay for chemotherapy administration, intravenous infusion technique; up to 1 hour, 
single or initial substance/drug, injection, pembrolizumab, 1 mg and laboratory services. You say that an 
authorization was obtained for 999 of HCPC J9271, which is valid from June 15, 2022 to September 28, 2022. 
The Plan denied your request. The Plan says that the Plans records show an approved authorization exists, 
however either the service performed, the servicing provider or the number of visits billed do not match what 
was approved on the authorization. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request for chemotherapy administration, intravenous infusion technique; up to 1 hour, 
single or initial substance/drug (96413), injection, pembrolizumab, 1 mg (J9271) and laboratory services 
provided on June 27, 2022. Specifically, the Plan has not provided us with the exact reason for the denial or 
documentation to support this denial. Therefore, we decided that the Plan has to pay for chemotherapy 
administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug (96413), injection, 
pembrolizumab, 1 mg (J9271) and laboratory services provided on June 27, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 February 2, 2022, by an 
out-of-network (OON) provider.
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 enrollee does not require intensive treatment or frequent 
physician interventions during rehabilitation. The Plan says that further treatment can be provided in a less 
intensive level of care setting. 
 
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 weakness and urinary tract infection. 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 medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay more for the colonoscopy and biopsy (45380) and colonoscopy with lesion 
removal (45385) provided on May 20, 2022. 
 
You asked the Plan to pay more for the colonoscopy and biopsy and colonoscopy with lesion removal. You say 
that getting polyps removed would be in the best interest of the Plan to pay for instead of paying for cancer 
treatments. You also say that the provider should have advised there would be a coinsurance before this service 
was rendered. The Plan denied your request. The Plan says that this claim processed correctly based on your 
benefits outlined in the Evidence of Coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable Medical Benefits Chart for this 
case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay more for the colonoscopy and biopsy (45380) and colonoscopy with lesion removal (45385) 
provided on May 20, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Next Generation Sequencing (NGS). 
 
You asked the Plan to pre-approve NGS. You say that the requested genetic testing is needed to help with the 
need for additional aromatase inhibitors used for treatment. The Plan denied your request. The Plan says the 
testing in dispute has been requested from a laboratory that is not CLIA-certified or certified by the New York 
State Department of Health's Clinical Laboratory Evaluation Program (CLEP). 
 
The Plan follows Medicare rules. Medicare rules say that NGS is only considered medically necessary if it is 
performed in a CLIA-certified laboratory.  
 
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 NGS. Our reviewer says that the criteria 
for coverage have not been met. Our physician reviewer found a search does not show the laboratory on the 
Center for Disease Control's (CDCs) CLIA certified laboratory list. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NGS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Next Generation Sequencing (NGS).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that the coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that daily 
skilled services are required. The enrollee has refused therapy services and no skilled nursing needs are 
documented. There is no documentation that the enrollee requires the services on an inpatient basis, only in a 
skilled nursing facility setting. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on July 1, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on July 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elbow orthosis (eo), with adjustable position locking 
joint(s), prefabricated, off-the-shelf provided to the enrollee on July 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not sufficiently support the billed supply code. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical provider documents include progress notes indicating the enrollee has chronic back pain 
and a previous lower extremity fracture. There is no clear documentation to indicate a need for an elbow 
orthosis that was provided on 7/14/22. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf 
provided to the enrollee on July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (0031U, 0032U, 0033U, 81225, 81227, 
81256, 81355, 81381, 81400 and 81401) billed for date of service September 6, 2019. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says there is insufficient documentation to support 
these services as billed. 
 
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 laboratory services have been met. 
Specifically, the records provided do not include a lab report or lab results for these tests. Without this 
information, it cannot be confirmed that these services were provided and reported correctly. Therefore, we 
decided that the Plan does not have to pay for laboratory services (0031U, 0032U, 0033U, 81225, 81227, 
81256, 81355, 81381, 81400 and 81401) billed for date of service September 6, 2019.
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 enrollee needs IRF care to return to being 
independent. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to 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 that the enrollee is medically stable and does not need a physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. At the current low functional level, the 
enrollee does not need 3 hours a day for 5 days a week of therapies with multidisciplinary approach in an IRF. 
The enrollee has no rehabilitation nursing needs other than routine nursing care and no medical complexity 
with high functional level. While the enrollee may benefit physical therapy and occupational therapy, the 
enrollee's rehab needs can be safely met in an alternate and low intensity setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99395 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 99395. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is non-covered. 
 
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 99395 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code 99395 is non-covered. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99395 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99395 billed for date of service May 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299) provided on January 8, 2022, 
to February 3, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 G0299 is not supported in the medical record. Specifically, the admission date on the 
Notice of Admission does not match the admission date on the claim. Based on this information, we decided 
that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the 
Plan does not have to pay for home health services (G0299) provided on January 8, 2022, to February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint radiofrequency ablation (RFA) 
procedure. 
 
You asked the Plan to pre-approve an SI joint RFA procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an SI joint RFA procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested SI joint RFA has not been proven effective and is considered 
experimental/ investigational. The review has determined that the requested SI joint RFA 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 an SI joint RFA procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac (SI) joint radiofrequency ablation (RFA) procedure.