Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the therapeutic, prophylactic, or diagnostic injection (96372), routine 
venipuncture (36415), blood count (85007), complete blood count (CBC) (85027), and romiplostim injection 
(J2796) provided on April 26, 2022. 
 
You asked the Plan to pay for the therapeutic, prophylactic, or diagnostic injection, routine venipuncture, blood 
count, CBC, and romiplostim injection. You say that you would like this claim to be reprocessed based on the 
medical necessity of the services provided. The Plan denied your request. The Plan says that charges for or in 
connection with services or supplies that are, as determined by the Plan, considered to be experimental or 
investigational are excluded from coverage under the enrollee's plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pay for the therapeutic, prophylactic, or diagnostic 
injection, routine venipuncture, blood count, CBC, and romiplostim injection. Our reviewer says that the 
requested drug and the services performed in conjunction with the injection in dispute were medically 
reasonable and necessary. Our physician reviewer found Nplate is a prescription medicine used to treat low 
blood platelet counts (thrombocytopenia) in adults with immune thrombocytopenia (ITP). In this case, the 
enrollee has a diagnosis of ITP and has been maintained on Nplate since October 2021. Our reviewer also 
found that the requested use of the romiplostim injection (J2796) is Food and Drug Administration (FDA) 
approved for the enrollees diagnosis. 
 
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 therapeutic, prophylactic, or diagnostic injection, routine venipuncture, 
blood count, CBC, and romiplostim injection. have been met. Therefore, we decided that the Plan has to pay 
for the therapeutic, prophylactic, or diagnostic injection (96372), routine venipuncture (36415), blood count 
(85007), complete blood count (CBC) (85027), and romiplostim injection (J2796) provided on April 26, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimzia. 
 
You asked the Plan to pre-approve Cimzia. You say that the enrollee may have poor venous access and the 
requested drug is the best choice. The Plan denied your request. The Plan says Cimzia is a non-preferred drug. There is no record that shows the enrollee has tried one of the preferred drugs (Inflectra, Remicade or Simponi 
Aria) and it hasn't worked, or that the enrollee has medical reasons that prevent them from using one of them.  
 
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. You can find this information on page 18 of the Plans 2023 Schedule of Cost Sharing. 
 
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 Cimzia. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drugs. Additionally, based on 
the medical records provided and the Medicare-approved major drug compendia, there is no indication that the 
Plans required drugs 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 Cimzia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Cimzia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90792) provided on 
January 24, 2023. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation 90792. You say that the notes support medical 
necessity. The Plan denied your request. The Plan says this code was billed with excluded diagnosis code 
pairing F19.94 and F19.10. 
 
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 90792 is psychiatric diagnostic evaluation with medical 
services. 
 
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 psychiatric diagnostic evaluation 90792. Our reviewer says 
that this code does not meet criteria for payment. Our reviewer found diagnosis code F19.10 has an exclusion 
for F19.94 per ICD-10 guidelines, which means these two diagnosis codes would not be reported together. 
Therefore, this service was incorrectly billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychiatric diagnostic evaluation 90792 have not been met. Therefore, we 
decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90792) provided on January 
24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two additional units of procedure code 99458 rendered on 
March 31, 2023. 
 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 while the documentation does support that excess units were provided, there was no specific 
rationale as required by the policy as to why additional units were needed to be performed. 
 
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 99458 is "Remote physiologic monitoring treatment 
management services, clinical staff/physician/other qualified health care professional time in a calendar month 
requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes 
(List separately in addition to code for primary procedure)." 
 
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 while the documentation does 
support that two additional units were provided, the documentation does not show why these additional 
services would be considered reasonable and necessary. 
 
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 two additional units of procedure code 99458 rendered on March 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional mileage. You say that you need transportation to an appointment 
at this facility. The Plan denied your request. The Plan says the requested transportation exceeds your mileage 
limit. 
 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 Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. We confirmed that the requested trip is 
greater than 50 miles of driving distance. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior tibial nerve stimulation (PTNS). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 services are not medically necessary. Our physician reviewer found the submitted records do not show that 
the enrollee has failed behavioral therapies or anticholinergic medications. The clinical documentation states 
that the overactive bladder is associated with spinal stenosis and that the enrollee is considering spinal surgery. 
This indicates that the enrollee has or may have neurogenic bladder, which excludes coverage of PTNS. The 
services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve posterior tibial nerve stimulation (PTNS).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation billed for date of service 
January 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was only transported one time. The 
Plan denied your request. The Plan says the service is not separately payable. 
 
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 find that ambulance services were provided while the enrollee was admitted for inpatient services. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance transportation billed for date of 
service January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says IRF care is not medically necessary. 
 
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 that the provided clinical documentation does not specify any active medical 
comorbidities or complex functional impairments; thus, the complexity of the enrollee's documented nursing, 
medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The clinical documentation shows that the enrollee requires 
ongoing skilled physical and occupational therapy but does not show that the enrollee would tolerate or require 
an intensive rehabilitation regimen. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says neither Medicare nor the enrollee's plan covers 
this request. Medical studies have not proven this service/item is helpful for the treatment of the enrollee's 
health problem. 
 
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 Cala Trio device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has essential tremors. She has used Primidone, topiramate propranolol, 
wrist weights for activities such as eating, putting on makeup, all without sufficient relief of the tremor. The 
tremor has worsened over time and interferes with basic activities of daily living. Medicare does not pay for 
any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or 
to improve the functioning of a malformed body member. There is insufficient evidence in the literature that 
this device is effective for the enrollee. The requested device is not the standard of care for this enrollee's 
tremor according to current guidelines. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio nerve stimulator device (K1018, K1019).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on January 14, 2023. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport, and ground 
mileage. You say that due to the enrollee's conditions any other form of transport is unsafe. The Plan denied 
your request. The Plan says the enrollee did not require the expertise of trained personnel or the equipment 
available only in an ambulance in order to effectuate a safe transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport, and ground mileage. Our reviewer says that the ambulance transport services were 
not medically necessary.  Our physician reviewer found the transportation via ambulance from the hospital to the enrollee's residence was 
not medically necessary. The enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided 
by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance service, basic life support, non-emergency transport, and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport, and ground mileage provided on January 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nine additional units of procedure code 99458 rendered on 
January 25, 2023. 
 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 provider has not documented any medically necessary reason for performing extra units in 
excess of the three allowed. 
 
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 99458 is "Remote physiologic monitoring treatment 
management services, clinical staff/physician/other qualified health care professional time in a calendar month 
requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes 
(List separately in addition to code for primary procedure)." 
 
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 records do not show any 
specific rationale for why the additional units needed to be rendered. The review has determined that the 
records did not support that the additional services were reasonable or necessary. 
 
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 nine additional units of procedure code 99458 rendered on January 25, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on June 6, 2022, to June 
29, 2022.  
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found the enrollee does not 
appear to have been homebound and did not have documented skilled nursing needs (i.e., intravenous (IVs), 
complex wound care, new ostomy). The enrollee did not have documented skilled therapy needs. As such, 
home health services were not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided on June 6, 2022, to June 29, 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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the service requested is not medically 
necessary.  
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided by a clinical social worker on 
October 11, 2022. 
 
You asked the Plan to pay for psychotherapy visit. You say that you are appealing this denial. The Plan denied 
your request. The Plan says there is no documented contact with the enrollee's attending or primary care 
physician. 
 
The Plan must follow Medicare rules. Medicare rules say that a clinical social worker must attempt to consult 
with the enrollees attending or primary care physician.  
 
We looked at the file and Medicare rules. The documentation does not include an attempt to consult the 
enrollees attending or primary care physician. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy visit have not been met. Therefore, we decided that the Plan does not have to pay 
for a psychotherapy visit provided by a clinical social worker on October 11, 2022.