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 on March 25, 2022 to April 23, 2022.

You asked the Plan to pay for the home health services. You say that this service was 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 January 24, 2022. The NOA was not received by the Plan until September 21, 2022. 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 on March 25, 2022 to April 23, 2022.
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 requires hourly rounding by nursing 
staff to decrease fall risks and therapy services. The Plan denied your request. The Plan says the services the 
enrollee needs can be provided safely in another setting such as a skilled nursing facility, home with home 
health services or home with outpatient therapy. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 You asked the Plan to pre-approve insertion of an ILR. 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 certain cardiac event monitors are 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical necessity for insertion of an ILR 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 insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) during sleep as an outpatient. This has not been tried and shown to fail as 
an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dynamic adjustable knee extension/flexion device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider did not send in any medical reason to support the need for the device 
provided by the out-of-network provider. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome.  
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation doesnt support that the joint is unstable or that there is joint laxity or 
significant deficits in extension.  Additionally, there is no clear indication that an in-network provider could not 
provide an appropriate knee orthosis. The requested knee orthosis is not medically 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a dynamic adjustable knee extension/flexion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93005 billed for date of service October 15, 
2022. 
 You asked the Plan to pay for procedure code 93005. The Plan denied your request. The Plan says payment for 
code 93005 is bundled into payment for code 12013. 
 
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 93005 
is a column II code to column I code 12013. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93005 billed for date of service October 15, 
2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve twelve additional outpatient PT visits. 
 
You asked the Plan to pre-approve twelve additional outpatient PT visits. You say that it is medically necessary 
for the enrollee to receive additional PT visits. The Plan denied your request. The Plan says that the enrollee 
does not meet criteria for additional PT visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan did not send us medical records. You say that it is 
medically necessary for the enrollee to receive additional PT visits. Without medical records, we cannot 
determine whether or not the enrollee meets Medicare criteria. Therefore, we decided that the Plan has to pre-
approve twelve additional outpatient PT visits.  
 
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 initial hospital care (procedure code 99223) rendered on 
September 9, 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the CPT code 99223. The documentation available for review does not support the encounter 
required decision making of high 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 99223) rendered on September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the intravitreal injection and the 
ophthalmic diagnostic imaging provided on January 13, 2023. 
 
You asked the Plan to waive the copayments for the intravitreal injection and the ophthalmic diagnostic 
imaging. You say that you say you have had macular degeneration for years and does not understand why you 
have a copayment. You say you cannot afford this kind of copayment since you go to the eye doctor frequently. 
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 $40 
copayment; a $40 copayment for per specialist office visit; other outpatient diagnostic tests.  
 
You have been asked to pay a $40 copayment for the intravitreal injection and a $40 copayment for the 
ophthalmic diagnostic imaging. The intravitreal injection falls within the Medicare Part B prescription drugs 
benefit category. The ophthalmic diagnostic test falls 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. Therefore, we decided that the Plan does not have to waive the copayments for the 
intravitreal injection and the ophthalmic diagnostic imaging provided on January 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71046 rendered on October 6, 2022. 
 
You asked the Plan to pay for the services. You say that the claim is billed correctly. The Plan denied your 
request. The Plan says procedure code 71046 is not supported when billed with diagnosis code F17.200. 
 
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 71046 is "Radiologic examination, chest; 2 views." 
 
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 medical and billing records 
provided indicate diagnosis code F17.200 (Nicotine dependence, unspecified, uncomplicated) was the only 
diagnosis billed in association with procedures 71046, and is not a valid diagnosis in order to perform this service, therefore CPT 71046 is not eligible for reimbursement consideration. The American College of Chest 
Physicians medical journal states In patients at risk for developing lung cancer, screening for lung cancer with 
[chest x-ray] once or at regular intervals is not recommended.  
 
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 procedure code 71046 rendered on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on December 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 Current Procedural Terminology (CPT) code 99223 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 care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit."

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 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 enrollee was hospitalized with leg pain and dementia. The history is limited with no exploration of the dementia and limited physical exam. There was no detailed respiratory, cardiovascular or abdominal exam. The plan was to stop and medication and obtain consults, which would be considered moderate complexity for decision-making. Key elements from history, physical and decision making were not present as per coding guidelines.

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 99223) rendered on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Interfyl injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says large population sufficiently powered randomized controlled trials that demonstrate 
long-term outcome advantages are needed. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that Interfyl connective tissue matrix is used to fill irregular spaces or soft-tissue deficits resulting from 
wounds, trauma, or surgery. Interfyl connective tissue matrix is suited for a variety of surgical applications 
when there is a need to replace or supplement damaged or inadequate integumental tissue. Evidence is lacking. Large well-designed studies in the peer review scientific literature comparing stand-alone use of Interfyl to 
established treatments are needed. Published studies do not demonstrate any long-term health outcome 
advantage with the use of Interfyl as an alternative to standard treatments. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Interfyl injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service November 
19, 2022. 
 
You asked the Plan to pay for procedure code 93042. You say that these services were medically necessary. 
The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 99291. 
 
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 93042 
is a column II code to column I code 99291 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 93042 billed for date of service November 19, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve SelectMDx testing (0339U) provided January 6, 2023. 
 
You asked the Plan to pre-approve SelectMDx testing. You say that the records provided support the necessity 
of the service in dispute. The Plan denied your request. The Plan says that SelectMDx is not a covered benefit 
because this is not a test which has met the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 SelectMDx testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found SelectMDx testing is medically reasonable and necessary in this case. The LCD criteria above 
have been met. In addition, NCCN Guideline Version 2022 Prostate Early Detection, includes the following 
statement regarding this test: Overall, the panel believes that SelectMDx score is potentially informative in 
patients who have never undergone biopsy, and it can therefore be considered in such individuals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SelectMDx testing have been met. Therefore, we decided that the Plan has to 
pre-approve SelectMDx testing (0339U) provided January 6, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 43 miles for routine transportation. 
 
You asked the Plan to pre-approve an additional 43 miles for routine transportation. You say that the service 
should be covered. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips with 50-mile limit trip per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 43 miles for routine transportation.