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 99223) rendered on 
December 5, 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 99223-57 (1 Unit) 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. 
 
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 record submitted 
includes an operative report for dual chamber pacemaker and anesthesia record. The medical record did not 
include an evaluation and management service provided on the same date of service. Therefore, the 
documentation is unable to verify the code and modifier. 
 
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 5, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 87640. We decided that the Plan does not have to pay for 87491.  
 
You asked the Plan to pay for laboratory services (procedure code 87491 and 87640) rendered on January 16, 
2023.. You say that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 87640.   
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 CPT 87640 is "Infectious agent detection by nucleic acid 
(DNA or RNA); Staphylococcus aureus, amplified probe technique." 
 
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 for CPT 87640. Our reviewer says that the laboratory 
report includes a test result for this procedure. Therefore, the code is verified. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
87640.  
 
We also decided that the Plan does not have to pay for 87491. 
 
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 CPT 87491 is "Infectious agent detection by nucleic acid 
(DNA or RNA); Chlamydia trachomatis, amplified probe technique." 
 
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 for CPT 87491. Our reviewer says that the laboratory 
report does not contain documentation of this procedure; therefore, it cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87491 have not been met. Therefore, we decided that the Plan does not have to 
pay for 87491. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional eight home health physical therapy visits 
(G0151). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
clinical documentation shows that patient is close to meeting stated goals. The goal was ambulating 100ft in 
home setting, and the enrollee is currently ambulating 90 feet. Thus, the records do not show that continued 
skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve 
the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level 
of function and/or prevent deterioration. The clinical documentation does not support the medical necessity of 
eight additional home health PT sessions. 
 
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 pre-approve an additional eight home health physical therapy visits (G0151).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
  You asked the Plan to pre-approve SNF care. You say that a continued SNF admission is medically necessary. 
The Plan denied your request. The Plan says  the continued SNF admission is not medically necessary after 
July 24, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued SNF care.
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 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 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 rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You can receive further services at a lower 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: Favorable

 
We decided that the Plan has to pre-approve radiation therapy treatment (99203, 77263, 77280, 77290, 
77300x3, 77307, 77331x3, 77334x3, 77336x2, 77427, G6007x8). 
 
You asked the Plan to pre-approve radiation therapy treatment. You say that you are requesting reconsideration 
due to medical necessity for plantar fascial fibromatosis. The Plan denied your request. The Plan says that 
although there are ongoing studies investigating the potential role of modern low-dose radiation therapy for 
plantar fasciitis and Achilles tendonitis, this type of treatment is currently considered investigational. 
 
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 radiation therapy treatment. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the use of radiotherapy to treat plantar fasciitis dates back many decades and is 
commonly practiced in Germany and other European countries. While radiotherapy is not commonly utilized 
for plantar fasciitis in the US, it is an effective treatment for which many US doctors (who would refer for 
radiation) are unfamiliar. However, it is an accepted standard for plantar fasciitis that is resistant to less 
invasive therapies. A 2014 randomized study of 200 patients >65 years of age with painful plantar fasciitis 
concluded: "Low-dose radiotherapy is effective in most patients with painful plantar fasciitis. Due to minimal 
side effects and low costs, it represents an excellent treatment option compared to conventional therapies or 
surgery."  Radiation for treatment-resistant plantar fasciitis, based upon published literature and guideline 
statements (from Germany) would be considered to be furnished with accordance of accepted standards of care. 
The decision is favorable for complex radiotherapy. It is not clear that 3 fields with complex shaping are 
needed (as that is not what was done in the trials above) though it is reasonable to use this approach. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy treatment have been met. Therefore, we decided that the Plan 
has to pre-approve radiation therapy treatment (99203, 77263, 77280, 77290, 77300x3, 77307, 77331x3, 
77334x3, 77336x2, 77427, G6007x8).  
 
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 Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says you do not meet the step therapy requirements. 
 
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 injections. Our physician reviewer 
found that the Plan requires a trial of zoledronic acid or another intravenous bisphosphonate therapy before 
they will approve Prolia. Our physician reviewer found that based on the medical records provided there is no 
indication that you tried and failed the required drug. Our physician reviewer found that there is no indication 
that the Plans required drug would likely be less effective and/or likely have adverse effects for you.  
 
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: 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 medical records provided support the 
need for LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for LTACH services.  
 
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 receiving acute hospital care, and acute care services have not been 
denied. The documentation does not support that the enrollee in this case requires services at the LTACH that 
are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this 
time. The documentation does not support that an additional 25 days of hospitalization are reasonably expected 
for the enrollee in this case.  
 
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 pay for inpatient hospital services billed with diagnosis code A41.59 
rendered from June 17, 2022, to June 21, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
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 DRG 872. 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 the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with altered mental status.  She was found to have hepatic encephalopathy, prerenal 
azotemia, hypokalemia and a urinary tract infection (UTI). There is no evidence of fever, leukocytosis, 
hypotension, hypoperfusion, acute organ failure due to infection or bacteremia. There is no evidence that the 
enrollee had sepsis. Therefore, the billing of A41.59 is not supported.  
 
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 billed with diagnosis code A41.59 rendered from June 17, 2022, to June 21, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the colon surgery to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says it is not medically necessary for surgery to be performed at out-of-
network provider. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found this surgery can 
be provided by an in-network provider. 
 
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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve the colon surgery to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal knee-shin system, single axis, fluid swing 
and stance phase control (L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), 
addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without 
adjustability (L5848) and addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856).  
You asked the Plan to pre-approve the prosthetics. You say that you need this device for mobility/amputation. 
The Plan denied your request. The Plan says the requested prosthetic parts exceed your needs. 
 
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 prosthetics. Our physician reviewer 
found the provided records from your treating physician in this case do not clearly explain why the requested 
K3 microprocessor knee is medically necessary and a K3 hydraulic knee would not meet your mobility needs. 
 
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 prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828), 
endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), addition to endoskeletal knee-shin 
system, fluid stance extension, dampening feature, with or without adjustability (L5848) and addition to lower 
extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, 
includes electronic sensor(s), any type (L5856).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Hydrocolloid dressing (A6234-A1) provided on February 7, 2023. 
 
You asked the Plan to pay for the Hydrocolloid dressing. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that these supplies are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services with a status indicator of P are 
not separately payable under the Physician fee schedule. If the item or service is covered as incident to a 
physician service and is provided on the same day as a physician service, payment for it is bundled into the 
payment for the physician service to which it is incident (an example is an elastic bandage furnished by a 
physician incident to a physician service). If the item or service is covered as other than incident to a physician 
service, it is excluded from the fee schedule (for example, colostomy supplies) and is paid under other payment 
provisions. 
 
In this case, we agree that the Hydrocolloid dressing provided has a status indicator of P on the Physician Fee 
schedule and would therefore not be separately payable under that fee schedule. However, according to the case 
file that the Plan sent to us, the only items/service billed on this date is the Hydrocolloid dressing at issue. 
There is no evidence that these items were provided incident to a physician service. According to Medicare 
rules, these items are therefore potentially payable under the Durable Medical Equipment, Prosthetics, 
Orthotics, and Supplies (DMEPOS) fee schedule. The Plan has failed to provide any evidence showing that 
these supplies would NOT be payable under the DMEPOS fee schedule. Further, it also appears that the Plan is 
alleging that the Hydrocolloid dressing was dispensed prior to the written order for the items. This is not 
corroborated in the documentation that the Plan sent to us. The records show that the Hydrocolloid dressing at 
issue was prescribed and ordered on February 3, 2023 (the same day of shipment), and the supplies were 
delivered on February 7, 2023. These are allowable dates for the order process. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Hydrocolloid dressing have been met. Therefore, we decided that the Plan has to pay for the 
Hydrocolloid dressing (A6234-A1) provided on February 7, 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.