Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on December 17, 2022, to 
December 23, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that medical 
records submitted supports diagnosis code A41.9. The Plan denied your request. The Plan says that after a 
thorough review of all the information in the submitted medical record, the review did not find sufficient 
documentation to clinically validate the diagnosis of A41.9 (Sepsis unspecified organism). 
 
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 principal diagnosis code, A41.9, defined as Sepsis 
unspecified organism. 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 physician reviewer found the patient had leukocytosis and 
tachycardia, meeting systemic inflammatory response syndrome criteria, and treated for pneumonia, therefore 
principal diagnosis code A41.9 is justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on December 17, 2022, to December 23, 2022, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that the requested drug is medically necessary in 
treating iron deficiency anemia. The Plan denied your request. The Plan says the requested drug has not met the 
required step therapy requirements necessary for approval. 
 
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 Feraheme. Our reviewer says that the 
requested drug does not meet the necessary criteria for approval. Our physician reviewer found the records 
provided does not show that the enrollee has tried and failed the Plan's preferred drugs, Infed and Venofer. 
Documentation does not support that Infed or Venofer would likely be less effective or have adverse effects for 
the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the hospital wants to discharge the enrollee as soon 
as possible. You state your home is not conducive to someone with a broken hip.  The Plan denied your 
request. The Plan says that the skilled nursing facility (SNF) services requested do not meet the requirements 
for approval. 
 
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 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that the enrollee has had functional and clinical 
status change thus would be expected to require assessment by skilled therapy and skilled nursing. The enrollee 
has wound/pain assessment needs, documented risks of post-surgical complications thus would be expected to 
require daily skilled 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 interrogation device evaluations (remote) (93294, 
93296) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pacemaker check. You say that you disagree with the denial and have 
attached clinical notes for review. The Plan denied your request. The Plan says the enrollee has a primary care 
physician (PCP) who is responsible for providing her routine health care needs. The enrollee must get approval 
from the PCP in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not approved by the enrollees PCP. The records show that the PCP 
disagrees with the request. We found no exception that would require the Plan to pre-approve these 
items/services. Therefore, we decided that the Plan does not have to pre-approve interrogation device 
evaluations (remote) (93294, 93296) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of a wireless pulmonary 
artery pressure sensor (CardioMEMS) (33289, C2624). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested service is experimental, investigational, and unproven. 
 
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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found at this time, the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of a wireless pulmonary artery pressure sensor (CardioMEMS) 
(33289, C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal fusion procedure (22842, 63045, 20930, 
22600). 
 
You asked the Plan to pre-approve the spinal fusion procedure. You say that this procedure 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 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 spinal fusion procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no spinal instability documented in the records. Records do not show a 
trial of physical therapy. 
 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 spinal fusion procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal fusion procedure (22842, 63045, 20930, 22600).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 8, 2023, billed with 
procedure code 99205-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99205-25 is office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter. 
 We find that CPT code 99205-25 is not supported in the medical record. Specifically, documentation does not 
include total time spent on the date of the encounter. As such, there is insufficient documentation to support the 
billed code. Based on this information, we decided that Medicare rules for coverage of the practitioner services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on May 8, 2023, billed with procedure code 99205-25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 1, 2023, billed with 
procedure code G0318. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this service is included in the primary 
procedure. 
 
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 practitioner services provided have 
been met. Specifically, no medical records for this date of services have been provided for review. Therefore, 
we decided that the Plan does not have to pay for practitioner services provided on March 1, 2023, billed with 
procedure code G0318.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36470 billed for date of service January 18, 
2023. 
 
You asked the Plan to pay for procedure code 36470. The Plan denied your request. The Plan says payment for 
code 36470 is bundled into payment for code 36465. 
 
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 36470 is a column II code to column I code 36465. Code 36470 was 
billed with a -59 modifier. The medical records do not show that the service billed with the -59 modifier was a 
distinct procedural service. 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 36470 billed for date of service 
January 18, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Home Health Aide (HHA) service. 
 
You asked the Plan to pre-approve the aide services. You say that the enrollee has signs of dementia and 
requires help in order to continue to live. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the documentation 
doesnt support that the member requires additional skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing or rehab services 
to effectively provide treatment, care, and/or services in order to improve the members condition. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Home Health Aide (HHA) service.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service January 5, 
2023, to February 3, 2023. You asked the Plan to pay for the billed services. You say that there was a glitch in the system. The Plan denied 
your request. The Plan says the NOA was not received timely.  
 
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 January 5, 2023. The NOA was not received by the Plan until March 29, 
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 the home health care billed for 
dates of service January 5, 2023, to February 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service May 11, 
2022, to May 31, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says an NOA was not 
submitted. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. For 
each admission to home health, the HHA notifies Medicare systems via submission of an NOA 
 
We looked at the file and the rules. The documentation does not show that an NOA was submitted. 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 the home health care billed for dates of service 
May 11, 2022, to May 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemodenervation with Botox (64644, 95874, and J0585) 
provided on January 19, 2023. 
 
You asked the Plan to pay for 64644, 95874, and J0585. You say that you are appealing this denial The Plan 
denied your request. The Plan says supporting records were not submitted to verify the codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of 64644, 95874, and J0585 have been 
met. Specifically, no records were submitted to the Plan to support the codes billed on this claim. Therefore, we 
decided that the Plan does not have to pay for chemodenervation with Botox (64644, 95874, and J0585) 
provided on January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
(87798) provided on May 12, 2023. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case the records show that this panel tested for more than 5 
respiratory pathogens. Based on this information, we decided that Medicare rules for coverage of the 
respiratory PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory polymerase chain reaction (PCR) panel (87798) provided on May 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 6, 2023, billed with 
codes 81191, 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81309, 81317 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 
February 6, 2023, billed with codes 81191, 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 
81309, 81317 and 81401.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injection. 
 
You asked the Plan to pre-approve sacroiliac joint injection. You say that the requested procedure is medically 
necessary due to the enrollee's age and functionality. The Plan denied your request. The Plan says the requested 
procedure does not meet the medical requirements for approval. 
 
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 sacroiliac joint injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation provided stated the physical findings included tenderness 
paraspinal region, tenderness of SI joint region, and no pain with pelvic range of motion testing. However, the 
required positive provocative testing on examination to confirm SI joint pain was not described in the 
documentation. At least three positive findings with provocative maneuvers: FABER, Gaenslen, Thigh Thrust 
or Posterior Shear, SI Compression, SI Distraction and Yeoman Tests are required to justify injection to the SI 
joint according to the LCD criteria. Therefore, without confirmation of the diagnosis and criteria not met, the 
injection will be considered 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 sacroiliac joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on February 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included int 
he global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99233) is included in the global 
surgery payment for the procedure (45378) provided on the same date of service. 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 the services (99233) provided on February 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87641, 87653, and 87798 billed for 
date of service April 20, 2023. 
 You asked the Plan to pay for procedure codes 87481, 87641, 87653, and 87798. The Plan denied your request. 
The Plan says payment for codes 87481, 87641, 87653, and 87798 is bundled into payment for code 87801. 
 
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 codes 
87481, 87641, 87653, and 87798 are column II codes to column I code 87801. 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 codes 87481, 87641, 
87653, and 87798 billed for date of service April 20, 2023.