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

 
We decided that the Plan does not have to pay for the services (99204) provided on January 5, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99204 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 moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter". 
 
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 use of code 99204 is not supported by the records provided. Our reviewer found that there is insufficient support for moderate level 
of medical decision-making or documented time treated of 45-59 minutes, to support this code. 
 
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 the services (99204) provided on January 5, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. 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. 
 
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 Prolia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you have not tried and failed the required 
drug. There is no documentation provided indicating that the plan's required drug would likely be less effective 
and/or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the functional electrical stimulation (FES) device 
(E0745). 
 
You asked the Plan to pre-approve the FES device. You say that you are requesting approval for FES due to 
damage to Spinal Cord causing Left Foot Drop and left leg weakness please see medical notes.  The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for this device. 
 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 FES device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that the requested device is being used to treat disuse 
atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other 
non-neurological reasons for disuse atrophy. The documentation does not reveal that the NMES/FES device is 
being used for a patient with a spinal cord injury who has completed at least 32 physical therapy sessions with 
the device over a period of three months as part of a one-on-one training program with the goal specifically to 
achieve walking, not to reverse or retard muscle atrophy. The documentation does not reveal that the enrollee 
has had a 3-month therapy training period with this device. The documentation must indicate this device is 
used for a goal of walking, not reversing muscle atrophy. Physical therapy notes indicate the enrollee is able to 
ambulate without this device. Furthermore, the documentation indicate that the enrollee also has peripheral 
polyneuropathy with axonal loss of electrodiagnostic testing therefore the documentation does not reveal that 
the enrollee has intact peripheral nerves from L1 and below.  
 
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 FES device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the functional electrical stimulation (FES) device (E0745).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary/rest home visit and injection provided on 
December 22, 2022. 
 
You asked the Plan to pay for domiciliary/rest home visit and injection. You say that the services should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary/rest home 
visit and injection provided on December 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on March 23, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that molecular signature testing offers the potential to improve treatment response by avoiding TNFi therapy when an individual is predicted to be a non-responder. Additional peer-reviewed published studies are 
warranted, including studies with diverse populations, validation of responders versus non-responders, and the 
ability of the test to contribute to the improvement of net health outcomes of individuals with RA. The review 
has determined that the requested PrismRA testing at issue 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the PrismRA test provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
February 09, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit for the 
evaluation and management provided on February 09, 2023.
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 a fast appeal as the 
enrollee currently meets LTACH admission criteria. The Plan denied your request. The Plan says the LTACH 
services requested do not meet the requirements for approval. 
 
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 appears to be improving but is not yet stable for transfer and 
requires short-term additional acute care services that can safely be provided at the current facility. 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 at this time 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: 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 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 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 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 is not medically necessary as the enrollee 
is not yet stable for transfer and as it would not be clinically advantageous at this time. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at L3 (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that the requested procedure is medically necessary. 
The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty is covered when all the criteria listed in 
the Medicare rules section 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 a kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the enrollee presented non-
hospitalized with moderate to severe pain that she rated at 8/10. However, the detailed documentation is not 
evident regarding worsening pain. There is no indication of a progression of the body height loss, greater than 
25% vertebral body height loss, kyphotic deformity, or a severe impact on her daily activities. Moreover, there 
is MRI corroboration of retropulsion. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at L3 (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing (G0483) provided on May 6, 2022, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that please find enclosed the following document 
to support the billing of G0483. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 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 the definitive drug testing (G0483) provided on 
May 6, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the step therapy 
criteria are not met. 
 
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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary in this case. Our physician reviewer found that 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on March 1, 2023, billed 
with code 99233. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says payment for this service is included in the 
payment for another service. 
 
The Plan must follow Medicare rules. Medicare rules say that in situations where a patient receives another 
evaluation and management (EM) visit on the same calendar date as critical care services, Practitioners must 
use modifier -25 on the claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital care provided have not been met. The service provided was not billed with 
the required modifier and is not separately payable. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care provided on March 1, 2023, billed with code 99233.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 26, 2021, to 
May 4, 2021, 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 was 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 secondary diagnosis code A41.1, described as 
Sepsis due to other specified staphylococcus. 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 the enrollee is a 57-year-old male who presented to the 
hospital with fever. Workup revealed a fever, moderately elevated blood pressure, tachycardia, tachypnea, 
normal oxygenation, Glasgow Coma Scale 15, normal bilirubin, normal platelets, Creatinine 1.21, and no 
oliguria. An infected Total parenteral nutrition catheter was found as likely contributing to fever and he was 
treated with antibiotics and fluids. Creatinine reduced to less than 1.2 with initial treatment. Although the 
enrollee appeared to have an infection and bacteremia, there was insufficient evidence of a dysregulated 
response leading to life-threatening organ failure. Sepsis 3 criteria was not met. Therefore, the code, A41.1 
(sepsis) is not supported for this admission.   
 
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 April 26, 2021, to May 4, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652), segmental pneumatic appliance for use with pneumatic compressor, full 
leg (E0667), and segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor, full leg segmental pneumatic appliance, and full 
arm segmental pneumatic appliance to be provided by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 
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 a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. 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 
a pneumatic compressor, segmental home model with calibrated gradient pressure (E0652), segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667), and segmental pneumatic appliance 
for use with pneumatic compressor, full arm (E0668) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were provided in good faith. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the observation services provided on 
March 13, 2023, to March 16, 2023. 
 
You asked the Plan to reduce the copayment for the observation services. You say that you were admitted to 
the hospital. 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 $350 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $350 copayment for the observation services. This item/service falls within the 
outpatient hospital observation 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. The record shows you were in hospital observation status. Therefore, we 
decided that the Plan does not have to reduce the copayment for the observation services provided on March 
13, 2023, to March 16, 2023.