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 needs this level of care. The Plan denied 
your request. The Plan says the enrollee's medical records do not show that the enrollee must have an intensive 
therapy program and services can be provided in other settings.  
 
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 intensive therapies. The enrollee's 
needs can be safely provided in an different 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 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: Favorable

 
We decided that the Plan has to pay for echocardiography, transesophageal (TEE) for monitoring purposes 
(93318) provided on March 24, 2023. 
 
You asked the Plan to pay for TEE procedure. You say that you disagree with the denial and request 
reconsideration of payment on this claim. The Plan denied your request. The Plan says that the records indicate 
a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between CPT 93318 
and 00567. 
 
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 TEE procedure. Our reviewer says that the service meets 
criteria for payment. Our reviewer found this is a TEE during a coronary artery bypass graft (CABG) with 
anesthesia. This appears to be covered with an appropriate modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TEE procedure have been met. Therefore, we decided that the Plan has to pay 
for echocardiography, transesophageal (TEE) for monitoring purposes (93318) provided on March 24, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 5, 2022, to 
January 3, 2023. 
 You asked the Plan to pay for the home health services. You say that you sent in the NOA on July 9, 2023. You 
also said that the Plan has not required a NOA for other claims. The Plan denied your request. The Plan says 
the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 8, 2022. The NOA was not received by the Plan until June 9, 2023. As 
more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this 
claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
December 5, 2022, to January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93307 billed for date of service March 21, 
2023.  
 
You asked the Plan to pay for procedure code 93307. The Plan denied your request. The Plan says payment for 
code 93307 is bundled into payment for code 93306. 
 
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 93307 
is a column II code to column I code 93306 with a modifier indicator of 0. The column II code is therefore not payable. 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 93307 billed for date of service March 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ear cartilage graft (21235), excise excess skin & 
tissue (15839), and augmentation of facial bones (21208). 
 
You asked the Plan to pre-approve the surgical procedures. You say that the enrollee needs these services 
because of their gender dysphoria. The Plan denied your request. The Plan says a psychological evaluation 
must be completed by two therapists. 
 
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 surgical procedures. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that the enrollee has gender dysphoria. The record provided 
does not document the presence of functional impairments or that the requested services are for the prompt 
repair of injury or accident. The record provided supports that the requested procedures are cosmetic in nature 
to improve the masculine features of the face. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested services. 
 
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 surgical procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an ear cartilage graft (21235), excise excess skin & tissue (15839), and 
augmentation of facial bones (21208).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monthly rental charge for a neuromuscular electrical 
stimulator (NMES) for date of service March 27, 2023.  
 
You asked the Plan to pay for the NMES rental charge . You say that this was medically necessary. The Plan 
denied your request. The Plan says the NMES is not covered for this indication.  
 
The Plan must follow Medicare rules. Medicare rules say that NMES is covered for treatment of disuse atrophy 
caused by non-neurological conditions. 
 
 We looked at the file and Medicare rules. Though the note does indicate the presence of disuse atrophy, there is 
insufficient information to confirm it is not related to neurological issues. The main reason for the NMES is 
noted to be pain relief, which is not among the covered indications. Based on this information, we decided that 
Medicare rules for coverage of the NMES rental charge  have not been met. Therefore, we decided that the 
Plan does not have to pay for the monthly rental charge for a neuromuscular electrical stimulator (NMES) for 
date of service March 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82306, 82607, 82728, 82746, 83540, 
83550) provided on April 19, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that your provider assured you that these tests 
would be covered by insurance. The Plan denied your request. The Plan says insufficient information was 
provided to review the medical necessity of this claim. 
 
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 services have been met. In this case the Plan requested medical records from your provider for review. These records were not received. 
Without this information we are unable to verify if the testing was medically necessary. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (82306, 82607, 82728, 82746, 83540, 83550) 
provided on April 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 10, 2022 to 
September 8, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the NOA to Original 
Medicare and you were not aware that you had to send it to the Plan. You said that the Plans' representatives 
could not assist you with filing the NOA. The Plan denied your request. The Plan says the NOA was not 
received. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan.  As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from August 10, 
2022 to September 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the semi-electric hospital bed (E0260) provided on April 14, 
2023. 
 
You asked the Plan to pay for the semi-electric hospital bed. You say that the item should be covered. The Plan 
denied your request. The Plan says this is a duplicate item. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you had a semi-electric hospital bed at the time the semi-electric hospital bed was received. 
a semi-electric hospital bed serves the same purpose as the semi-electric hospital bed. Therefore, we decided 
that the Plan does not have to pay for the semi-electric hospital bed (E0260) provided on April 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 20, 2022, 
through July 19, 2022.  
 You asked the Plan to pay for the home health services. You say that the NOA was submitted timely, so this 
claim should pay. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 20, 2022. The NOA was not received by the Plan until January 11, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Though a copy of the NOA was included in the file by the appellant, there was no evidence 
included to support that it was received by the Plan within the timely filing window.  Therefore, we decided 
that the Plan does not have to pay for the home health services provided from June 20, 2022, through July 19, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) supplies purchased on 
September 23, 2022, through November 20, 2022. 
 
You asked the Plan to pay for the DME supplies. You say that the items should be covered. 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 for the supplies provided in this case. No physician orders 
were submitted. 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 the durable medical equipment 
(DME) supplies purchased on September 23, 2022, through November 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered on January 11, 2023. 
 
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 Current Procedural Terminology (CPT) code 99223-57 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level, or that at least 75 
minutes were spent. 
 
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 evaluation and management services (procedure code 99223) rendered on January 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuation of inpatient hospital care provided on 
February 2, 2023, to February 16, 2023. 
 
You asked the Plan to pay for the continuation of inpatient hospital care. You say that the records provided 
support the need for the inpatient services provided. The Plan denied your request. The Plan says the enrollee 
no longer met the criteria for an extended inpatient hospital stay, as of February 2, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the continuation of inpatient hospital care. 
Our reviewer says that the requested inpatient hospital care was not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was admitted to the hospital with pneumonia, 
encephalopathy, malnutrition, and was treated with antibiotics, fluids, and nutrition support. Provided 
documents from February 2, 2023, described the enrollee with resolved pneumonia, stable hemodynamically, 
and awaiting discharge to a psychiatric facility. A lower level of care would have been appropriate on this date, 
and extended inpatient acute care services were not supported. 
 
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 continuation of inpatient hospital care have not been met. Therefore, we 
decided that the Plan does not have to pay for a continuation of inpatient hospital care provided on February 2, 
2023, to February 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0691). 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that the item should be covered. The 
Plan denied your request. The Plan says there is no clinical indication for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that UV light therapy systems are covered for 
selected patients with generalized intractable psoriasis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does 
not have to pay for the ultraviolet (UV) light therapy system (E0691).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve JOBST Farrow adjustable compression wrap. 
 
You asked the Plan to pre-approve JOBST Farrow adjustable compression wrap. 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 a gradient compression wrap is only covered when it 
is used as a primary or secondary dressing over wounds that meet the statutory requirements for a qualifying 
wound (surgically created or modified, or debrided). 
 
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 JOBST Farrow adjustable compression 
wrap. Our reviewer says that the services are not medically necessary. Our physician reviewer found you did 
not have the required indication, a wound, for this gradient compression garment to support its coverage, according to the provided notes and LCD criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of JOBST Farrow adjustable compression wrap have not been met. Therefore, we 
decided that the Plan does not have to pre-approve JOBST Farrow adjustable compression wrap.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 24, 2023 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on March 24, 2023
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous (IV) insulin therapy (OIVIT) 
services provided on May 2, 2023. 
 
You asked the Plan to pay for the OIVIT services. The Plan denied your request. The Plan says the billed 
services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication. 
 
We looked at the file and Medicare rules. Per Medicare rules, the requested OIVIT services are not medically reasonable and necessary, and therefore are not covered. Based on this information, we decided that Medicare 
rules for coverage of the OIVIT services have not been met. Therefore, we decided that the Plan does not have 
to pay for the outpatient intravenous (IV) insulin therapy (OIVIT) services provided on May 2, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the step therapy requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. If a Plan decides to apply step therapy requirements to Part B drugs, they must 
disclose that information in the ANOC and EOC documents. 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 has not provided a copy of the EOC to show whether it has 
implemented step therapy requirements. Therefore, we decided that the Plan has to pre-approve Prolia.  
 
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 supplies identified with codes A6010, A6248, and A6197 for 
date of service July 15, 2022. 
 
You asked the Plan to pay for codes A6010, A6248, and A6197. You say that you disagree with the Plan's 
denial. 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 for the supplies provided in this case. Review of the file 
shows that the physician order did not include a date. 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 supplies identified with codes A6010, A6248, and A6197 for date of service July 15, 2022.