Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for home health care services provided from 
June 26, 2022, to October 20, 2022. 
 
You asked the Plan to reimburse you for home health care services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health care services have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for home health care services provided from June 26, 2022, to October 20, 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 enrollee was fully independent and 
functional at home and deserve the best opportunity to fully recover from acute illness and regain 
independence. The Plan denied your request. The Plan says the enrollee's records do not show the need for 
continued treatments that can only be given in a hospital setting, when ready to leave the hospital, services may 
safely be received in another setting, at a skilled nursing facility at home with home health 
services or outpatient setting if appropriate. 
 
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 available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 
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.
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 enrollee has had a complicated 
prolonged hospitalization and it is in the medical opinion the enrollee be admitted to long term care. The Plan 
denied your request. The Plan says services requested do not meet the requirements for approval, when the 
enrollee is ready to leave the hospital, services can safely receive this care in another setting, at a Skilled 
Nursing Facility or at home with home health services. 
 
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 available at the LTACH that the enrollee requires that are not available at the current health care setting being offered by the health plan. 
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has plaque psoriasis. He 
has not tried and failed the Plan's required drugs, Enbrel, Humira, Otezla, or Skyrizi. The records do not show 
that the required drugs would be contraindicated or less effective; therefore, Ilumya is not reasonable or 
medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99219 and 99225 billed for dates of service 
November 1, 2022, to November 22, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes cannot be verified. 
 
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. 
 The CPT Code Manual definition of code 99225 is subsequent observation 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. 
 
We find that CPT codes 99219 and 99225 are not supported in the medical record. Specifically, the records do 
not include a comprehensive or expanded problem-focused exam on the dates of service at issue.. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99219 and 99225 billed for dates of service 
November 1, 2022, to November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal and replacement of an implanted continuous 
glucose monitor (CGM). 
 
You asked the Plan to pre-approve implanted CGM. You say that the enrollee is insulin dependent and unable 
to poke a finger due to unsteady hands and tremors. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for a CGM, and as the enrollee does not have an existing implanted CGM there is no 
need for a removal procedure.  
The Plan must follow Medicare rules. Medicare rules say that I-CGMs are only covered if certain criteria are 
met.  
 
We looked at the file and Medicare rules. The record does not show that the enrollee is insulin-treated with 
multiple (3 or more) daily administrations of insulin or a continuous subcutaneous insulin infusion pump. 
Based on this information, we decided that Medicare rules for coverage of implanted CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve removal and replacement of an implanted 
continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 22, 2022, 
through April 25, 2022, and billed with diagnosis code N17.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis N17.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of N17.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.9-Acute kidney 
failure, unspecified. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the secondary 
diagnosis of N17.9-Acute kidney failure, unspecified. Our physician reviewer found the member presented to 
the emergency room with epigastric and right upper quadrant pain. The member was noted to have chills, 
nausea, and dry heaving. The provider noted to be calculus of the gallbladder. The member had elevated white 
blood cells count of 13.7. The assessment noted the member with cholelithiasis with positive murphy sign. The 
member had hyperbilirubinemia and required a gastrointestinal (GI) consult for possible choledocholithiasis. 
Therefore, diagnosis code N17.9-Acute kidney failure, unspecified is the appropriate secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 22, 2022, through April 25, 2022, and billed with diagnosis 
code N17.9.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen or methane test (91065). 
 
 
 You asked the Plan to pre-approve a breath hydrogen test. You say that you feel acid in your mouth and with 
the requested test, it will show that you have a dry mouth and that something is wrong. The Plan denied your 
request. The Plan says lactulose breath hydrogen test for diagnosing small bowel bacterial overgrowth is 
excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules show that a lactulose breath hydrogen for diagnosing 
small bowel bacterial overgrowth and measuring small bowel transit time is excluded from coverage and not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of a breath hydrogen 
test have not been met. Therefore, we decided that the Plan does not have to pre-approve a breath hydrogen or 
methane test (91065).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 25, 2022, billed with 
codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, and 
87798. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
code. We looked at the file and Medicare rules. The urinary tract infection (UTI) panel was not billed with a single 
panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on October 25, 2022, billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 
87563, 87591, 87641, 87651, 87653, 87661, and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 3, 2022, billed 
with codes 81201, 81295, 81298, 81307 and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 3, 2022, billed with codes 81201, 81295, 81298, 81307 and 81317.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 3, 2022, through 
June 14, 2022, and billed with diagnosis code G93.41. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis G93.41 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of G93.41. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93. 41-Metabolic 
encephalopathy. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support secondary 
diagnosis of G93. 41-Metabolic encephalopathy. Our physician reviewer found the member oriented and was 
alert which put the member's mental status at baseline. The member's Glasgow coma scale was at 15. The 
member had demonstrated an increased confusion amidst hospitalization and experienced a Glasgow coma 
scale (GCS) of 14. Though the member's score improved to 15 but it returned to 14. This is due to a previous 
stroke as verbalized by the member. Therefore, diagnosis code G93. 41-Metabolic encephalopathy is the 
appropriate secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 3, 2022, through June 14, 2022, and billed with diagnosis code 
G93.41.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services provided July 29, 2021, to September 29, 2021. 
 
You asked the Plan to pay for the inpatient services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that routine items and services are not covered. 
 
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. Review of the file shows that the Plan states routine items and services are not 
covered. The Plan also states that some of the charges/dates of service have been overturned. The 
documentation is unclear to what services are being denied and what services are being covered. The Plan did 
not substantiate their denial. Therefore, we decided that the Plan has to pay for the inpatient services provided 
July 29, 2021, to September 29, 2021.  
 
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 procedure code 93971 billed for date of service December 8, 
2022. 
 You asked the Plan to pay for procedure code 93971. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93971 is bundled into payment for code 93970. 
 
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 93971 
is a column II code to column I code 93970. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93971 billed for date of service December 8, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the requested drug is necessary for the enrollee's plan of 
care. The Plan denied your request. The Plan says the enrollee has not tried and failed bisphosphonate therapy. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
the enrollee has tried and failed the required drugs. There is no documentation provided indicating that the 
plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable neurostimulator (L8769 and 64555). 
 
You asked the Plan to pre-approve implantable neurostimulator. You say that this is not considered to be 
acupuncture. You say that this would reduce the enrollee's need for use of narcotics. You also say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the request is not for spinal 
cord stimulation. The Plan says it is for an auricular stimulator that is placed behind the ear, and Medicare does 
not cover this type of device. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantable 
neurostimulator (L8769 and 64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service September 15, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 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. 
 
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 procedure code 99223. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee was admitted with nausea and 
vomiting. The documentation does not support a comprehensive history. Therefore, code 99223 is not 
supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 for date of service September 15, 2022.