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

 
We decided that the Plan does not have to pay for radiological services provided on June 8, 2022. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 24, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the radiology services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for radiological services provided on June 
8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that HBO therapy is a well-supported therapy for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee does not meet criteria for this 
service. 
 
The Plan follows Medicare rules. Medicare rules state that HBO therapy is only covered for certain indications. 
 
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 HBO therapy. Our reviewer says that 
the enrollee does not meet criteria for HBO therapy. Our physician reviewer found the enrollee has sudden 
idiopathic sensorineural hearing loss. The enrollee does not have a covered indication for HBO 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 HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 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 Hyalgan. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has not trialed one of the preferred viscosupplemental treatments, such as Orthovisc or Supartz 
FX. Step therapy, as outlined by the Plan, requires that one of these be trialed first. The documentation does not 
outline contraindications or reasons these medications were not considered or that the Plans additional 
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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Hyalgan (J7321).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 31, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says this claim must first by processed by the enrollee's primary 
insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has Specifically, 
the Plan has directed the provider to the enrollee's primary insurer. As the secondary insurer, the Plan cannot be 
held responsible for laboratory services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation procedure (64635). 
 
You asked the Plan to pre-approve the procedure. You say that you are in constant pain in your back and the 
first injections did not help. The Plan denied your request. The Plan says the records do not support that the 
medically necessary criteria has been met for the requested service. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the minimum criteria for a successful block is 80%. This was not achieved and therefore 
another block is deemed 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint radiofrequency ablation procedure (64635).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services 
 
You asked the Plan to pre-approve the inpatient services. You say that you are appealing the denial for 
authorization of inpatient services. You are in constant fear of something happening to you while you are alone. 
The Plan denied your request. The Plan says the condition can be treated on an ambulatory basis with an 
increase of the amount of visits with the psychiatrist and with revision or optimization of medications. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based upon review the records provided, this enrollee was not showing any 
dangerousness to self or others and has not been exhibiting severe psychological or psychiatric impairment 
requiring this level of care. The enrollee was not showing any perceptual disturbance, psychosis or aggressive 
behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the partial 
hospitalization level of care rather than a lower level of care as he did not have any suicidal or homicidal 
thoughts or behavioral disturbance and his symptomatology could be treated at a lower level of care. This 
enrollee was not showing any severity of psychological or psychiatric illness. Based upon review the records 
provided, this enrollee does not meet the criteria for treatment at partial hospitalization level of care and could 
have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation and 
was not showing any severe psychological or psychiatric impairment requiring this 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 the inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient psychiatric services
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs this ventilator to breath. 
A standard timeframe would jeopardize the enrollee's health and life. This machine will keep the enrollee out 
of the hospital and prevent her demise. The Plan denied your request. The Plan says records show that the 
enrollee is requesting AVAPS mode to treat her COPD. The records do not show that the enrollee has tried and 
failed a BiPAP machine in AVAPS mode. The request is not medically necessary. 
 
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 service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease. The record indicates 
that the enrollee was successfully treated with BiPAP. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability. The plan has indicated coverage for such a 
device is available upon request. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
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 (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) billed on May 9, 2022. 
 
You asked the Plan to pay for initial hospital care (99223). You say that the additional documentation should 
be reviewed, and the claim processed for payment. The Plan denied your request. The Plan says procedure code 
99223 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 inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
  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 initial hospital care (99223). Our reviewer says that 
procedure code 99223 is not supported. Our reviewer found procedure code 99223 requires a comprehensive 
history, comprehensive examination and high complexity of medical decision making. The provided records in 
this case do not document a comprehensive history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care (99223) have not been met. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99223) billed on May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233 x 3 and 99232 x 2) 
provided from February 23, 2022, through February 27, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; 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 patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. The definition of code 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key 
components: An expanded problem focused interval history; An expanded problem focused examination; 
Medical decision making of moderate 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 patient is responding inadequately to therapy or 
has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital 
floor or unit. 
 
We asked our medical 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 found for 
procedure code 99233 the records did not support that two (2) of following three (3) components were 
supported in the records1) detailed interval history 2) detailed examination 3) medical decision making of high 
complexity. For code 99232, the records did not support that 2 of following 3 components were supported in 
the records 1) detailed interval history 2) detailed examination 3) medical decision making of moderate 
complexity. 
 
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 the subsequent hospital care (99233 x 3 and 99232 x 2) provided from February 23, 2022, 
through February 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you have been in the intensive care unit 
for 4 weeks and need LTACH level of care. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, and your needs can be provided in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The health plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services (procedure code 95937, 95938, 95955) 
rendered on November 17, 2021. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says this was 
denied for being experimental and 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 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 intraoperative neuromonitoring (IONM) services are not readily supported for use in lumbar spine 
procedures. The data are insufficient to support a recommendation regarding the use of neuromonitoring as a 
modality that can be used for the preservation of nerve root function during lumbar fusion surgery. Given the conflicting evidence to date and the overarching consensus that further study is necessary to evaluate the use of 
IONM in lumbar spine surgery, the requested service is not supported as 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurology services (procedure code 95937, 95938, 95955) rendered on November 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Methlprednisolone sodium succinate, 
Famotidine, Diphenhydramine, and Hydrocortisone sodium succinate. 
 
You asked the Plan to pre-approve Keytruda, Methlprednisolone sodium succinate, Famotidine, 
Diphenhydramine, and Hydrocortisone sodium succinate. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda, Methlprednisolone sodium 
succinate, Famotidine, Diphenhydramine, and Hydrocortisone sodium succinate. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Methlprednisolone sodium succinate, Famotidine, Diphenhydramine, 
and Hydrocortisone sodium succinate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Keytruda, Methlprednisolone sodium succinate, Famotidine, Diphenhydramine, and 
Hydrocortisone sodium succinate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular monitoring services (code 93270) provided on 
September 12, 2022 
 
You asked the Plan to pay for cardiovascular monitoring services. The Plan denied your request. The Plan says 
with the information we have, we cannot determine how the member came to the servicing provider, or 
whether the services are medically necessary. 
 
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 cardiovascular monitoring services 
have been met. Therefore, we decided that the Plan does not have to pay for cardiovascular monitoring services 
(code 93270) provided on September 12, 2022
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. You say that there is no need to keep the enrollee in 
an acute hospital setting and may transition to next level of care safely and continue with the medical plan. The 
Plan denied your request. The Plan says the enrollee is receiving medically necessary acute/critical care and is 
being treated appropriately in the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.