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

 
We decided that the Plan does not have to pay for home health services provided from August 27, 2022, to 
September 9, 2022. 
 You asked the Plan to pay for the home health services. You say that you provided quality care to the enrollee, 
and these services were medically necessary. 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 August 27, 2022. The NOA was not received by the Plan until April 10, 
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 August 27, 2022, to September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide.  
 
You asked the Plan to pay for a stair glide. You say that the item is medically necessary. The Plan denied your 
request. The Plan says this is a non-covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esomeprazole magnesium. 
 
You asked the Plan to pre-approve the medication. You say that you need this medication. 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 esomeprazole magnesium.   
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: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99223 billed for date of service June 11, 2022. 
 
You asked the Plan to pay for 99223. You say that 99223 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99223 is denied because it is not supported in the 
documentation. 
 
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 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 99223. Our reviewer says that 99223 is not 
supported in the documentation. Our reviewer found the documentation from June 11 describes the enrollee as 
status post hip surgery, with normal examination findings, stable vitals, with a plan for ongoing pain control, 
anti-hypertensive medication management, and deep vein thrombosis (DVT) prophylaxis. The provided 
documentation did not have a comprehensive history or examination, nor was there documentation supporting a 
high level of decision-making to support the code 99223. Also, the duration of the encounter was not described 
as lasting 75 or more minutes. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99223 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services described by code 99223 billed for date of service June 11, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira pens. 
 
You asked the Plan to pre-approve the medication. You say that prior to this denial the enrollee had been on 
this medication since about 2018. 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 Humira pens.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 You asked the Plan to pre-approve myocardial perfusion imaging. 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 SPECT is covered when specific criteria are met. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is insufficient 
documentation to support the medical necessity for the requested cardiac stress testing in this enrollee's 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 myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care, radiation services 
and urgent care visit provided on February 8, 2023, to July 11, 2023. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care, radiation services and urgent care visit. 
You say that you disagree with the cost share. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $195 
copayment per day for days 1-7 for inpatient hospital care, a 20% coinsurance for urgently needed services, a $25 copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $195 copayment per day for days 1-7 for inpatient hospital care, a 20% 
coinsurance for urgently needed services, a $25 copayment for outpatient diagnostic tests. The total allowed 
amount for the diagnostic test is $426.73 ($426.73 x 20% = $85.34). However, since the allowed amount is less 
than the standard copayment, you only owe $82.34. The total amount you are being asked to pay is $302.34 
($195 + $25 + $82.34 = $302.34). This item/service falls within the inpatient hospital care, outpatient 
diagnostic tests and urgently needed services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for inpatient hospital care, radiation services and urgent care visit provided on February 8, 2023, to July 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary and 
covered under Medicare guidelines. The Plan denied your request. The Plan says there is not a medical need to 
control these power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates that the enrollee has adequate strength to 
manage standard power drives. Therefore, the reviewer found that the requested upgraded electronics are not 
medically reasonable or 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve upgraded electronics (E2311, E2313, E2377).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 64488, 36620, 76937, 3655, 76376, 93325, 93320, 
93312 billed for date of service June 26, 2023. 
 
You asked the Plan to pay for the billed services. You say that anesthesia was medically necessary. The Plan 
denied your request. The Plan says that an operative report was not 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. 
 
We looked at the file and the rules. The medical records provided show that the billed services were provided. 
An operative report is not needed as the records submitted substantiate the billed services. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request. Therefore, we decided that the Plan has to pay for procedure codes 64488, 36620, 76937, 3655, 
76376, 93325, 93320, 93312 billed for date of service June 26, 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 pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 1, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. 
The Plan denied your request. The Plan says the services are not supported. The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 1, 2023.
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 will benefit from and meets Medicare 
Criteria for Acute Inpatient Rehabilitation that cannot be accomplished at a lower level of care. The Plan 
denied your request. The Plan says the enrollee's condition does not meet all the requirements for inpatient 
rehabilitation admission. The Plan says services may be provided at a lower level of care.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a left atrial appendage closure (LAAC) 
device (33340) and transesophageal echocardiography (93355). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary.  
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is the medical necessity of implanting a left atrial appendage closure device in this 
enrollee in whom there is elevated risk of a thromboembolic stroke due to atrial fibrillation and an elevated 
CHADS2VASC score.   
 
 
The enrollee is felt to be at high risk of bleeding and oral anticoagulation is therefore felt to be contraindicated.   
While there is reference to consideration of the LAAC, there is no documentation of performance of an 
evidence-based shared decision-making interaction on anticoagulation. As such, guidelines would not support 
implantation of a LAAC device in this setting. In summary, LAAC device placement would not be considered 
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantation of a left atrial appendage closure (LAAC) device (33340) and 
transesophageal echocardiography (93355).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 8, 2021, through 
June 11, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the acute inpatient hospital care should 
be covered as billed because it is supported in the documentation. The Plan denied your request. The Plan says 
that records do not support that criteria were met for acute inpatient services in this case, therefore payment is 
denied.  
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found this case pertains to a 78-year-old with bipolar disorder who was found by their family to be 
down and to not in their usual mental state. They were brought to the emergency department. The enrollee had 
an extensive workup to determine the etiology of their encephalopathy, including head imaging to rule out 
metastases given a prior history of bladder cancer. They were treated for a urinary tract infection (UTI), though 
it was later determined to be a contaminant. Medications were trialed/changed during the hospitalization 
because the enrollee's mental status was not at their baseline. Psychiatry was also consulted. The Plan's audit 
indicates that because no medical or infectious cause was identified for their encephalopathy, that the enrollee 
did not meet inpatient criteria, but this could only be determined after a thorough work up, as this enrollee 
received. It was reasonable to assume an inpatient stay would be required when they were admitted, especially 
because the documentation supports a change in their mental status throughout much of their hospitalization. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from June 8, 2021, through June 11, 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: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 88184 and 88185. We decided that the Plan does not 
have to pay for procedure codes 88341 and 88342.  
 
You asked the Plan to pay for the lab testing billed for date of service May 17, 2023. You say that 
reimbursement should be reconsidered. The Plan says that the codes cannot be separately reimbursed. 
 
We decided that the Plan has to pay for procedure codes 88184 and 88185.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and the rules. The Plan denied code 88184 as inclusive to code 88342. We have 
confirmed that code 88184 is a column I code to column II code 88342. Column I codes are separately payable. 
Because primary procedure code 88184 is payable, the add-on code, 88185, is also payable. Therefore, we 
decided that the Plan has to pay for procedure codes 88184 and 88185 billed for date of service May 17, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 88341 and 88342. 
 
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 88342 is a column II code to column I code 88184. The code at issue, 
88342, was billed with the -59 modifier. Providers may bill services with a -59 modifier if the service billed 
with the modifier indicates a distinct procedural service. The records do not show that the service billed with 
the -59 modifier was a distinct procedural service. Because primary procedure code 88342 is not payable in this 
case, the add-on code 88341 is also 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 codes 88341 and 88342 
billed for date of service May 17, 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 pay for the evaluation and management services coded as 99497 and 
the electrocardiogram interpretation and report coded as 93010 billed on May 23, 2023. 
 
You asked the Plan to pay for 99497 and 93010. You say that 99497 and 93010 should be paid as billed 
because they are both supported in the documentation. The Plan denied your request. The Plan says payment 
for 99497 is bundled into payment for code 99223, billed on the same date of service. 93010 is denied because 
it is not supported in the documentation.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, we have confirmed that code 99497 is a column II code 
to column I code 99223. 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. Regarding code 93010, we have confirmed 
that the provided documentation does not include an interpretation and report of an electrocardiogram. 
Therefore, 93010 is not supported. Based on this information, we decided that Medicare rules for coverage of 
99497 and 93010 have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management services coded as 99497 and the electrocardiogram interpretation and report coded 
as 93010 billed on May 23, 2023.