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

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
December 29, 2021, through December 31, 2021. 
 You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed based on 
medical necessity. The Plan denied your request. The Plan says rules for SNF care have 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 pay for the SNF care. Our reviewer says that the 
billed SNF care was not medically reasonable and necessary. Our physician reviewer found the enrollee was 
medically at or near baseline upon return from the acute care hospital and had no daily skilled nursing needs. 
She had severe chronic functional impairment and daily skilled therapy services were not medically necessary 
as the services were not appropriate for her advanced illness and chronic impairment. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from December 29, 2021, through December 
31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) and a heel stabilizer (L3170) 
for the left foot provided on March 1, 2022. 
 
You asked the Plan to pay for an ankle-foot orthosis and a heel stabilizer. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the items at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for an ankle-foot orthosis (L1971) and a heel stabilizer (L3170) for the left foot 
provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injection at a third spinal level on 
November 4, 2021. 
 
You asked the Plan to pre-approve the third level facet joint injection. You say that this claim should be paid in 
full. The Plan denied your request. The Plan says the payment request for a third level facet injection which 
was reviewed on pre-authorization request is not approved. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are intended to diagnose facet 
pathology. One or two bilateral levels are covered, but additional levels can only be allowed when 
documentation clearly supports the need. 
 
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 third level facet joint injection. Our reviewer says that the requested third level of facet joint injection is not considered medically necessary. Our 
physician reviewer found the enrollee has chronic low back pain with radiation to the thighs. He has tried anti-
inflammatory drugs, lidocaine patches, and hydrocodone. The number of levels exceeds utilization 
criteria.  Therefore, only 2 levels were medically reasonable or necessary. No unique circumstances were 
documented to support the necessity of the additional level. 
 
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 third level facet joint injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the facet joint injection at a third spinal level on November 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiography (TTE) 
with doppler provided on March 18, 2022. 
 
You asked the Plan to waive the copayment for the TTE with doppler. You say that you did not request the 
service and the cost is unnecessary. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $275 
copayment for diagnostic radiology imaging services.  
 
You have been asked to pay a $275 copayment for the TTE with doppler. The TTE with doppler falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 waive the copayment for a transthoracic echocardiography (TTE) with doppler provided on 
March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing (81479) provided October 29, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denial and requesting 
for processing of the claim in-network since you are the only service provider for Guardant Reveal. The Plan 
denied your request. The Plan says the clinical value and effectiveness of Guardant Reveal testing have not 
been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the Guardant Reveal testing (81479) provided October 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services coded 15734 provided on April 23, 
2021. 
 
You asked the Plan to pay for the surgery services as billed. You say that you would like these services 
reprocessed and approved for payment. The Plan denied your request. The Plan says the records do not support 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 15734 is muscle, myocutaneous, or fasciocutaneous flap; 
trunk. 
 
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 surgery services as billed. Our reviewer says that the 
documentation does not support the services as billed. Our reviewer found Operative report does not include enough documentation to confirm the donor site for the fasciocutaneous flap, and therefore cannot be verified.  
Operative report documents "began by identifying the right paraspinous muscle. The anterior investing fascia 
was dissected to the most lateral border and the lateral fascia was then released with bovie electrocautery. The 
muscle was then transferred from the donor site to the recipient midline. I then turned our attention to the left 
paraspinous muscle. The anterior investing fascia was dissected to the most lateral border and the lateral fascia 
was then released with bovie electrocautery. The muscle was then transferred to the midline defect. Per the 
National Correct Coding Initiative Edits Policy Manual:  "Reporting of a muscle, myocutaneous, or 
fasciocutaneous flap differs from that of other flaps as the procedure is always identified by the donor site, 
never by the recipient site. Therefore, the criteria for coverage of the services have been billed. 
 
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 surgery services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgery services coded 15734 provided on April 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Supartz FX (J7321). 
 
You asked the Plan to pre-approve Supartz FX. 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 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 Supartz FX. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Orthovisc, Synvisc or Synvisc One before they will approve the requested drug, 
Supartz FX. There is no indication that the enrollee has tried and failed the required drugs. Based on the 
medical records provided and the Medicare-approved drug compendia, there is no indication that the Plan's 
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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Supartz FX (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0861) (power tilt and power seat elevator). 
 
You asked the Plan to pre-approve the power wheelchair. You say that please reconsider the documentation 
provided for the wheelchair and accessories that are medically necessary to meet the enrollee's current needs. 
The Plan denied your request. The Plan says the enrollee does not have medical need for the multiple power 
options included in the requested group 3 power wheelchair K0861. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that this enrollee 
meets Medicare criteria for the requested group 3 power wheelchair with multiple power options (K0861) 
(power tilt and power seat elevator). The enrollee does meet criteria for the power tilt function, but the power 
seat elevation feature is statutorily non-covered as it serves no primary medical purpose. As the seat elevation 
feature is not covered, then the multiple power options feature is not covered. The enrollee appears to meet 
Medicare criteria for a group 3 power wheelchair with a single power option. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861) (power tilt and 
power seat elevator).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and was treated with diuretics. The enrollee was at a minimal assist level for functional 
mobility. She does not require skilled nursing or therapy services on a daily basis. She does not meet severity 
of illness or intensity of service criteria for an inpatient basis 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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aortography provided during a surgical procedure on 
August 11, 2021, billed with code 75630-XU. 
 
You asked the Plan to pay for the services as billed. You say that this should be paid as billed. The Plan denied 
your request. The Plan says there is no evidence to support separate payment for 75630.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 75630 is a column II code to column I code 37221; however, 75630 
was billed with a modifier.  
 
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 as billed. Our reviewer says that the 
documentation does not support the use of modifier -XU to bypass the PTP edit in this case. Our reviewer 
found the procedure report describes an angiogram was performed followed by intervention. Code 75630-XU 
Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialgraphy, radiological 
supervision and interpretation could be reported if the decision to treat was based on the findings of the 
angiogram. The documentation does not support CPT 75630 a separate procedure from CPT 37221, which 
includes operative angiograms and/or venograms. Therefore, separate payment for this code cannot be verified. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the aortography provided during a surgical procedure on August 11, 2021, billed with 
code 75630-XU.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital evaluation and management (EM) services 
provided on February 27, 2022, billed with code 99233. 
 
You asked the Plan to pay for the inpatient EM services as billed. You say that these services were provided by 
physician of two different specialties. These are both payable by Medicare. The Plan denied your request. The 
Plan says that two units of 99233 were billed by this provider. The denial was partially overturned to approve 
one unit, but the second unit remains denied. 
 
Please note that the Plan indicated that this denial was partially overturned and would allow payment for one 
unit of this code. However, payment has already been made for one unit for the services of a second physician. 
The claim at issue bills only for one unit. It was not clear what payment, if any, was approved for the services 
of the provider named in this decision. As such, we processed this appeal for payment of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that two EM visits may be paid to two physicians of 
the same group as long as they are of different specialties and are billed with different diagnosis codes. 
 
We looked at the file and Medicare rules. The provider at issue in this case has a specialty of pulmonary 
medicine/critical care. The physician for the paid claim is a nephrologist. Different diagnosis codes were billed 
on these claims. Separate payment is allowed for the services at issue. Based on this information, we decided 
that Medicare rules for coverage of the inpatient EM services as billed have been met. Therefore, we decided 
that the Plan has to pay for the subsequent hospital evaluation and management (EM) services provided on 
February 27, 2022, billed with code 99233.  
 
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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee is medically stable and does not need PM&R physician's supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. No acute rehab nursing needs identified or documented. At the current functional level, the 
enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach in an IRF. The enrollee's rehab needs can be safely provided in a lower 
intensity and alternate setting such as in a skilled nursing facility or in-home with therapies. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
January 28, 2022, through February 26, 2022. 
 You asked the Plan to pay for the SNF care rendered. You say that it is felt that Medicare payment can be made 
for the dates in question. The Plan denied your request. The Plan says Medicare payment was correctly denied 
for these dates. 
 
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 pay for the SNF care rendered. Our reviewer says 
that the SNF services provided on the dates of service in question Our physician reviewer found the enrollee is 
a female with multiple sclerosis, sepsis, and urinary tract infection. From a nursing perspective, the beneficiary 
received oral and inhaled medications and completed a course of IV antibiotics. The beneficiary had stable vital 
signs. She used oxygen via nasal cannula. Regarding rehabilitation services, the beneficiary did not require 
skilled therapy for the dates in question.   
 
There are no identifiable skilled nursing or therapy service needs. This beneficiary does not meet severity of 
illness or intensity of service criteria for an inpatient basis 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 the SNF care rendered have not been met. Therefore, we decided that the Plan 
does not have to pay for the skilled nursing facility (SNF) services provided from January 28, 2022, through 
February 26, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot. 
 
You asked the Plan to pre-approve the requested services. You say that the alternative drug is not financially 
feasible for the provider's office. The Plan denied your request. The Plan says the enrollee has not tried and 
failed Eligard. 
 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 the requested services. Our physician 
reviewer found that the enrollee has metastatic prostate cancer. 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, 
Eligard. 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. 
 
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 Lupron Depot.