Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on 
August 13, 2022. 
 
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 the documents do not support this level of care. 
 
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 99222 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 moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that examination findings were 
focused and included no acute distress, diminished breath sounds bilaterally but otherwise unremarkable. The 
patient was diagnosed with acute congestive heart failure and was continued on diuretics, started home meds 
with some changes. The enrollee was stable. The provided documentation did not sufficiently support a 
comprehensive history or examination and did not support medical decision-making of moderate complexity. 
 
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 initial hospital care (procedure code 99222) rendered on August 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram provided on January 13, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for an electrocardiogram. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an electrocardiogram provided on January 13, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 1, 2022, to 
August 4, 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 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 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, described 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 reviewer says that documentation does not support the billed code. 
Our physician reviewer found that in this case, there was no clinical or laboratory evidence of sepsis.  
 
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 August 1, 2022, to August 4, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the botox (J0585). 
 
You asked the Plan to pre-approve the botox. You say that the botox is medically necessary. The Plan denied 
your request. The Plan says there has not been a step therapy trial of a clinically equivalent product.  
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 the botox. Our physician reviewer 
found the Plan requires a trial of drug Dysport and Xeomin, before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the Plans required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the botox have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the botox (J0585).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable for 
transfer. The Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
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 the enrollee is not stable and requires additional acute care services that can safely be 
completed at the current facility until they are stable for transfer. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Completion of treatment at 
the current facility is recommended.   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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you are requesting reconsideration for the denial 
of a PET scan with concern for early-onset Alzheimer's disease versus frontotemporal dementia.  The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the information provided for review does 
not demonstrate that the enrollee meets diagnostic criteria for either Alzheimer's disease or frontotemporal 
dementia. The records suggest a cognitive impairment but does not demonstrate that diagnostic requirements 
were 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 the PET scan have not been met.  Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal lumbar interbody fusion. 
 
You asked the Plan to pre-approve transforaminal lumbar interbody fusion. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have 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 transforaminal lumbar interbody fusion. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found no compelling rationale is presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested transforaminal 
lumbar interbody fusion, in this case, is 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 transforaminal lumbar interbody fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transforaminal lumbar interbody fusion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342 and 88360 billed for date of 
service December 10, 2021. 
 You asked the Plan to pay for procedure code(s) 88341, 88342 and 88360. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342 and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342 and 88360 billed for date of service December 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 5, 2022, to 
September 23, 2022. 
 You asked the Plan to pay for the home health services. You say that you have supplied the required NOA. 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 September 5, 2022. The NOA was not received by the Plan until January 3, 
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 September 5, 2022, to September 23, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lucentis injection of the right eye (J2778). 
 You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the clinical information received from the enrollee's provider does not 
indicate that the enrollee has tried or have been unsuccessful with conservative treatment. 
 
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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Avastin and Eylea, before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the Plans required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Lucentis injection of the right eye (J2778).
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 you are requesting an expedited 
reconsideration stating the enrollee meets the criteria for a medically appropriate LTACH admission. The 
Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.  
 
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 the enrollee requires additional acute care services that can safely be completed 
at the current facility until more appropriate and stable for transfer. There are no services at the LTACH that 
the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH 
would not be clinically advantageous and completion of treatment at the current facility is recommended.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visits, the ECGs, and the 
injections provided on January 3, 2023, and January 4, 2023. 
 
You asked the Plan to waive the cost share for the specialist office visits, the ECGs, and the injections. You say 
that you have already paid $300 for each visit. 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 $35 
copayment for services from a specialist. Your contract with the Plan also clearly says that you must pay a $20 
copayment for Medicare-covered non-radiological diagnostic services. Your contract with the Plan also clearly 
says that you must pay 20 % coinsurance for Medicare-covered Part B drugs. 
 
You have been asked to pay a $35 copayment for each specialist office visit provided on January 3, 2023, and 
January 4, 2023. These items/services fall within the physician/practitioner services, including doctors office 
visits benefit category. You have also been asked to pay $4.85, which is less than the standard copayment for 
the ECG provided on January 3, 2023. You have also been asked to pay $5.02, which is less than the standard 
copayment for the ECG provided on January 4, 2023. These items/services fall within the outpatient diagnostic 
tests and therapeutic services and supplies 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. 
 
You have also been asked to pay 20% coinsurance of the allowed amount for the injections. These 
items/services fall within Medicare Part B prescription drugs benefit category. 
 
Date of Service Code Allowed Amount 20% Coinsurance 
January 3, 2023 J3490 $1,000 $50 
January 3, 2023 J2405 $1.08 $0.22 
January 3, 2023 J2250 $0.72 $0.14 
January 3, 2023 J7050 $0.67 $0.13 
January 3, 2023 J3475 $6.08 $0.80 
January 3, 2023 J2550 $2.94 $0.59 
January 4, 2023 J3490 $1,000 $50 
January 4, 2023 J2405 $1.08 $0.22 
January 4, 2023 J2250 $0.72 $0.14 
January 4, 2023 J7050 $0.67 $0.13 
January 4, 2023 J3475 $6.08 $0.80 
January 4, 2023 J2550 $2.94 $0.59 
 
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 cost share for the specialist office visits, the ECGs, and the injections 
provided on January 3, 2023, and January 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reverse right shoulder replacement. 
 
You asked the Plan to pre-approve a reverse right shoulder replacement. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have 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 a reverse right shoulder replacement. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found no compelling rationale is presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested reverse right 
shoulder replacement, in this case, is 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 a reverse right shoulder replacement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a reverse right shoulder replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3301 billed for date of service October 31, 
2022.  
 
You asked the Plan to pay for procedure code J3301. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code J3301 is 16. The MAI value for this code is 3. You billed 18 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code J3301 have not been met.  Therefore, we decided that the 
Plan does not have to pay for procedure code J3301 billed for date of service October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid swing and stance phase control (L5828), stance 
flexion feature (L5845), fluid stance extension (L5848), microprocessor control feature (L5856), flex-walk 
system or equal (L5981), multi-axial rotation unit (L5986). 
 You asked the Plan to pre-approve the items. You say that the enrollee meets the definition of a functional level 
3 amputee. The Plan denied your request. The Plan says the requested prosthesis/prosthetic parts exceed the 
enrollee's need and cannot be approved. 
 
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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that these items exceed the enrollee's medical needs, as the documentation indicates the enrollee uses a 
walker, and at times a scooter. The use of a walker and scooter are not consistent with K3 ambulation. The 
enrollee's activities and functions do not require a microprocessor knee. The physician documentation does not 
support why the enrollee requires a microprocessor over a mechanical knee.  
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a fluid swing and stance phase control (L5828), stance flexion feature (L5845), fluid stance 
extension (L5848), microprocessor control feature (L5856), flex-walk system or equal (L5981), multi-axial 
rotation unit (L5986).