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

 
We decided that the Plan does not have to pre-approve Tezspire. 
 
You asked the Plan to pre-approve the medication. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tezspire.  
 
Benefits for the medication 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the remote evaluations of defibrillator and pacemaker (93296 and 
93294) provided on June 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure codes 93296 and 93294. You say that you would like the Plan to 
reconsider their denial of payment as the services took place in New Jersey and should be covered under your 
previous policy prior to May 31, 2023. The Plan denied your request. The Plan says that the services received 
were neither emergent nor urgent and prior authorization was not obtained to seek OON care. 
 
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. You believe the services should have been covered under your old policy. In this 
case, the Plan has not provided any documentation showing the billed date of service was the correct date of 
service for the remote evaluations of defibrillator and pacemaker (93296 and 93294) provided. The file does 
not show the Plan requested medical records to determine that the correct date of service was billed. Therefore, 
we decided that the Plan has to pay for the remote evaluations of defibrillator and pacemaker (93296 and 
93294) provided on June 27, 2023, by an out-of-network (OON) provider.   
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the laminectomy, facetectomy and foraminotomy (63047 and 63048) 
provided on April 5, 2023. 
 
You asked the Plan to pay for the laminectomy, facetectomy and foraminotomy (63047 and 63048). You say 
that the records support the codes billed and the claim should be processed for payment. The Plan denied your 
request. The Plan says that procedure code 63047 is considered inclusive to procedure code 22214 and 
procedure code 63048 is not supported by the medical records submitted. 
 
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 says procedure code 63047 is considered inclusive to 
procedure code 22214 and procedure code 63048 is not supported by the medical records submitted. However, 
the Plan did not submit the medical records to support that procedure codes 63047 and 63048 should not be 
paid. Therefore, we decided that the Plan has to pay for the laminectomy, facetectomy and foraminotomy 
(63047 and 63048) provided on April 5, 2023.  
 
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: Favorable

 
We decided that the Plan has to pay for the lab testing for C. difficile toxin provided on April 10, 2023, billed 
with code 87324.  
 
You asked the Plan to pay for the testing as billed. You say that this was billed correctly.  The Plan denied your 
request. The Plan says that this testing was for genes by nucleic acid amplification, and there is a more 
appropriate code for this testing.   
 
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 87324 is infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], 
enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric 
assay [IMCA]), qualitative or semiquantitative; Clostridium difficile toxin(s). 
 
We find that CPT code 87324 is supported in the medical record. Specifically, the Plan's argument is not 
supported. There is no evidence to suggest that the toxin gene was being tested for by amplified probe. The 
report indicates that testing was for the toxin only by immunoassay. Based on this information, we decided that 
Medicare rules for coverage of the testing as billed have been met. Therefore, we decided that the Plan has to 
pay for the lab testing for C. difficile toxin provided on April 10, 2023, billed with code 87324.   
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure device billed for date 
of service April 22, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support medical necessity. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the continuous positive airway pressure device billed for date of 
service April 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 25, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring active non-pneumatic compression 
garment system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this system is helpful for treatment. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is noted to have lymphedema affecting the lower extremities. The documentation 
indicates that the patient has tried conservative measures, including compression garments and lymphedema 
therapy. There is no indication that the enrollee has trialed a basic pneumatic compression device and failed to respond with objective measurements. There is also a lack of medical literature indicating that the requested 
Koya Dayspring Device non-pneumatic compression device is clinically as or more efficacious than standard 
pneumatic compression devices. The medical literature largely includes pilot studies with a small number of 
participants. Therefore, the requested Koya Dayspring non-pneumatic compression device cannot be 
considered 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Koya Dayspring active non-pneumatic compression garment system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extra wide heavy duty hospital bed (E0303). 
 
You asked the Plan to pay for the extra wide heavy duty hospital bed. You say that this bed is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, 
E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The records do not show that the enrollee weighs more than 350 
pounds. Based on this information, we decided that Medicare rules for coverage of the extra wide heavy duty 
hospital bed have not been met. Therefore, we decided that the Plan does not have to pay for an extra wide 
heavy duty hospital bed (E0303).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for the hospital observation services, and inpatient 
hospital stay provided from September 13, 2022, to September 16, 2022. 
 
You asked the Plan to waive the cost sharing for the hospital observation services and inpatient hospital stay. 
You say that you were not in these facilities on these dates of services. The Plan denied your request. The Plan 
says that the cost sharing was applied correctly. 
 
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 medical records showing the services that were 
provided. Without medical records we are unable to confirm that the cost sharing was correctly applied. 
Therefore, we decided that the Plan has to waive the cost sharing for the hospital observation services, and 
inpatient hospital stay provided from September 13, 2022, to September 16, 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 pre-approve hyperbaric (HBO) oxygen therapy (G0277) and 
physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, 
per session (99183). 
 
You asked the Plan to pre-approve HBO oxygen therapy and physician supervision. 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 follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 oxygen therapy and physician 
supervision. Our reviewer says that the services are not medically necessary. Our physician reviewer found you 
do not meet criteria for hyperbaric treatment as it is not clear it is warranted or if other treatments have been 
pursued. 
 
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 oxygen therapy and physician supervision have not been met. Therefore, 
we decided that the Plan does not have to pre-approve hyperbaric (HBO) oxygen therapy (G0277) and 
physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, 
per session (99183).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99219 for date of service March 24, 2021. 
 
You asked the Plan to pay for procedure code 99219. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 99219 is initial observation 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 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 problem(s) 
requiring admission to outpatient hospital "observation status" are of moderate severity. Typically, 50 minutes 
are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99219 is not supported in the medical record. Specifically, this service was billed with a 
place of service 21 (inpatient hospital). This observation code should not be billed with place of service 21. 
This means this code is not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99219 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99219 for date of service March 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission for a shoulder arthroplasty. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no documentation to support an inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that detailed documentation is not evident regarding a significant past and/or current 
medical history that would place this enrollee at increased risk for peri-surgical complications requiring an 
inpatient stay.  There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the enrollee does not require an inpatient stay for 
this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient admission for a shoulder arthroplasty.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 3, 2023, to June 
1, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 3, 2023, to June 1, 
2023.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient behavioral health services provided from March 20, 
2023, to April 21, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that an incorrect 
revenue code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We looked at the file and the rules. The chart the Plan cites, found in the Medicare Claims Processing Manual, 
Chapter 1, Section 170.1, identifies selected Types of Bill and revenue codes for (some) services payable.  
The Plan has not provided explicit instructions in regard to billed code 90853 when billed with revenue code 
0905. Based on this information, we decided that Medicare rules for coverage of the billed services have been 
met. Therefore, we decided that the Plan has to pay for the outpatient behavioral health services provided from 
March 20, 2023, to April 21, 2023.  
 
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 pre-approve skin graft services. 
 
You asked the Plan to pre-approve the requested services. You say that the skin graft may be used as a wound 
covering in various surgical procedures. The Plan denied your request. The Plan says the request is not 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that Artacent AC skin substitute graft was requested. 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 requested 
services are not indicated for the enrollee's condition. Artacent skin substitute is not medically necessary for 
treatment of the surgical wound in this 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skin graft services.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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 it was documented that the enrollee previously failed assisted living facility. The 
enrollee has not failed SNF for which the enrollee appears more appropriate. The enrollee's needs can be met at 
lower level of care such as a skilled nursing facility (SNF). 
 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.