Persius/hicric huggingface dataset:
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 will benefit from 3 hours of daily inpatient rehabilitation to help return to highest level of function. The Plan denied your request. The Plan says the enrollee doesn't meet all the requirements, medically necessary care may be provided safely in a lower level of care.

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.

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 code 99226 billed for dates of service September 5, 2021, 
and September 6, 2021. 
 
You asked the Plan to pay for code 99226. You say that the medical records support payment for this code. The 
Plan denied your request. The Plan says code 99266 is not supported in the medical record because the records 
don't support a detailed interval history and medical decision making of high complexity. 
 
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 99226 is subsequent observation 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. 
 
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 code 99226. Our reviewer says that code 99226 is not 
supported by the medical record. Our reviewer found a detailed interval history requires 4+ elements or 3+ 
chronic conditions in the history of present illness, 2-9 review of systems and 1 pertinent element of past, 
family and social history. A detailed examination requires 6 body areas or organ systems and medical decision 
making of high complexity requires an extensive number of diagnoses or management options, an extensive 
amount and complexity of data reviewed and high risk of complication. The history in this case does not 
include 4+ elements or 3+ chronic conditions in the history of present illness, 2-9 review of systems and 1 
pertinent element of past, family and social history. The examination does include at least 6 body areas or 
organ systems. The medical decision making does not include an extensive number of diagnoses or 
management options, an extensive amount and complexity of data reviewed and high risk of complication.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99226 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99226 billed for dates of service September 5, 2021, and September 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a sacroiliac joint injection (code 27096) provided on January 12, 2022. 
 
You asked the Plan to pay for the sacroiliac joint injection. You say that this procedure does meet the criteria 
for an ambulatory surgery center. The Plan denied your request. The Plan says that this procedure does not 
meet the criteria for an ambulatory surgery center. 
 
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. Specifically, the Plan has not provided the Medicare rule to substantiate the 
denial for code 27096. Therefore, we decided that the Plan has to pay for a sacroiliac joint injection  
(code 27096) provided on January 12, 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 hospital care (procedure codes 99223 and 99233) rendered 
from August 21, 2022, to August 25, 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 documents do not support this level of care. 
 
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 the denied codes is: 
 
CPT 99223: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
CPT 99233: 
 
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." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there was no admission note 
submitted for 8/21/22. Therefore, CPT 99223 is not supported. In terms of CPT 99223, the medical decision 
making was of moderate complexity on the rest of the dates of service. The history and exam were problem-
focused, not comprehensive. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital care (procedure codes 99223 and 99233) rendered from August 21, 2022, to August 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel (81455) 
provided on September 14, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that the referring provider felt that the testing was 
medically necessary for the enrollee and the services should be covered. The Plan denied your request. The 
Plan says the referring provider is a naturopathic doctor. Medicare guidelines state that Medicare does not 
cover visits to naturopathic doctors (NDs), and the request for payment cannot be approved. 
 
Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules also say 
that Medicare does not cover visits to naturopathic doctors under any condition. 
 The Plan must receive prior authorization from an in-network or out-of-network provider for laboratory 
services. The Plan did not pre-approve the item/service at issue. The referring provider in this case is a 
naturopathic provider. Medicare rules that naturopathic services are not covered under any condition. 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 a targeted genomic sequence analysis panel (81455) provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on August 12, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory testing. You say that that there was no time to research 
authorization requirements before treating the enrollee. The Plan denied your request. The Plan says there is 
insufficient documentation to support why the services should be paid. with the documentation provided, it 
cannot be determined how the enrollee came to the servicing provider, or whether the services were performed 
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 the laboratory testing have been met. 
Specifically, the documentation provided does not indicate how the enrollee came to the servicing provider, or 
whether the services were performed as billed. The record indicates that the Plan made multiple attempts to 
obtain this information, but none was received. Therefore, we decided that the Plan does not have to pay for the 
laboratory testing provided on August 12, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration (90471) 
provided on October 27, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you went in for a routine exam. You say that 
your doctor recommended you have this vaccine. You also say that you were not told this would not be 
covered. The Plan denied your request. The Plan says the vaccine services in this case are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) and 
administration (90471) provided on October 27, 2022.  
 
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Micrographically Oriented Histographic Surgery 
(MOHS) surgery (17313, 17314). 
 
You asked the Plan to pre-approve the Micrographically Oriented Histographic Surgery (MOHS) surgery. You 
say that the service is medically necessary. The Plan denied your request. The Plan says the squamous cell 
lesion is not located on prior radiated skin, or an area of a traumatic scar, and there is no history of genetic 
syndromes. 
 
The Plan follows Medicare rules. Medicare rules say that 
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 Micrographically Oriented 
Histographic Surgery (MOHS) surgery. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found the patient has developed keratoacanthoma on the skin of mid upper arm that can be 
removed via regular excision. 
 
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 Micrographically Oriented Histographic Surgery (MOHS) surgery have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Micrographically Oriented 
Histographic Surgery (MOHS) surgery (17313, 17314).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75746 and 76937 billed for date of service 
October 1, 2022. 
 
You asked the Plan to pay for procedure codes 75746 and 76937. You say that these services were necessary 
and are supported in the medical records. The Plan denied your request. The Plan says the records provided are incomplete and do not identify the patient. In addition, it cannot be verified that code 76937 was reported 
correctly, as the payment for this service is generally included in another service 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 procedure codes 75746 and 76937 
have been met. Specifically, the medical records provided appear incomplete and do not include any 
identifying information for the patient/enrollee. Therefore, we decided that the Plan does not have to pay for 
procedure codes 75746 and 76937 billed for date of service October 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested Orthovisc is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Euflexxa first. 
 
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 Orthovisc. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertebroplasty procedure. 

You asked the Plan to pre-approve the requested services. You say that the pain affects the enrollee's daily 
living. The Plan denied your request. The Plan says the requested procedure is contraindicated. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is only covered 
under certain medical 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 the requested services. Our physician 
reviewer found that there is no documentation in the records that the fracture is less than 6-12 weeks old on 
imaging studies. The coverage criteria have not been met. Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vertebroplasty procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure.  

You asked the Plan to pre-approve the requested services. You say that the enrollee has limited mobility due to 
fracture. The Plan denied your request. The Plan says the enrollee does not have increased edema. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is only covered 
under certain medical 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 the requested services. Our physician 
reviewer found that the enrollee is being treated for wedge compression fracture of third lumbar vertebrae. He 
presented with back pain that is worse. The pain slightly moves into the hip and now has pain moving up the 
left back. The exam reveals left sacroiliac joint tenderness. detailed documentation is not evident regarding an 
acute or subacute compression fracture. The magnetic resonance imaging (MRI) stated no significant increased 
T2 signal intensity is identified to indicate an acute or subacute process. There is also evidence of retropulsion 
of the compression fracture. Moreover, multiple other plausible pain generators including at the lumbosacral 
spine are evident without clear evidence of failure of recent, reasonable, comprehensive less invasive 
conservative care measures. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested kyphoplasty, 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
October 24, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 01, 2020. The Plan 
denied your request. The Plan says that an individual provider cannot bill for OTP services. 
 
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. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on October 24, 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 the office visit (99203) provided on September 16, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee's primary care 
physician asked for the enrollee to be seen in this clinic. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 provider in this case is not a network provider with the Plan. 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 the office visit (99203) provided on September 16, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel testing provided on December 
21, 2022. 
 
You asked the Plan to pay for the respiratory pathogen panel testing. You say that your lab performed the 
testing that was ordered by the patient's doctor. The Plan denied your request. The Plan says this denial was 
appropriate as the service is not considered reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory pathogen panels where more than 5 
pathogens are performed in the outpatient setting are not considered medically reasonable and necessary. In 
this case, the records show that nine respiratory pathogens were tested, exceeding Medicare's coverage rules. 
Therefore, we decided that the Plan does not have to pay for the respiratory pathogen panel testing provided on 
December 21, 2022.