Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the pneumatic compressor, segmental home model without 
calibrated gradient pressure (E0651) and segmental pneumatic appliance for use with pneumatic compressor, 
full leg (E0667). 
 
You asked the Plan to pre-approve the pneumatic compression device and appliances. You say that please 
review the case based on the medical policy for secondary lymphedema. The Plan denied your request. The 
Plan says that a pneumatic compression device is not reasonable or necessary. 
 
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 the pneumatic compression device and 
appliances. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found this enrollee has lower extremity edema due to prior 
surgery and infection for a left distal tibia and fibula fracture. The enrollee has been compliant with 
conservative measures prescribed by their lymphedema therapist. A pneumatic compression device is now 
being prescribed to intensify the therapy. External compression is used with the aim of decreasing interstitial 
fluid production and reducing excess lymph fluid in the affected extremity. It is to intensify the therapy. The 
service is reasonable and 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 pneumatic compression device and appliances have been met. Therefore, we 
decided that the Plan has to pre-approve the pneumatic compressor, segmental home model without calibrated 
gradient pressure (E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg 
(E0667).  
 
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 code 99213-25 billed for date of service November 29, 2022. 
 
You asked the Plan to pay for code 99213-25. You say that code 99213-25 is separately payable from other 
services on that date of service. The Plan denied your request. The Plan says the use of the 25 modifier to allow 
for separate payment of code 99213 billed for date of service November 29, 2022, is not supported by the 
medical record. It is included with code 20610 billed for the same date. 
 
The Plan follows Medicare rules. Medicare rules say that use of modifier 25 indicates a significant, separately 
identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure 
or other therapeutic service. Both services must be significant, separate and distinct.  
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 code 99213-25. Our reviewer says that the 
use of the 25 modifier to allow for separate payment of code 99213 is not supported. Our physician reviewer 
found this procedure was previously scheduled and no new evaluation was performed for this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99213-25 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99213-25 billed for date of service November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99490-59 billed for date of service November 3, 2022. 
 
You asked the Plan to pay for code 99490-59. You say that the 59 modifier was appended appropriately, so this 
code should be paid. The Plan denied your request. The Plan says the medical records do not support separate 
payment for code 99490-59. This service was performed on the same day as 20552, and therefore 99490 is 
considered inclusive and not separately payable. Please note that codes 76942-GA and 99152-59-GA have been 
overturned and are not at issue. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 99490-59 Our reviewer says that the 
use of the 59 modifier to allow for separate payment of code 99490 is not supported by the medical record. Our physician reviewer found the medical record includes documentation of a trigger point point procedure, as well 
as care management services provided on the same date of service. In this case the care management service is 
directly related to the injection, which has a 0 day global period. Therefore, modifier -59 is not supported, as 
the care management service was not a distinct procedural service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99490-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99490-59 billed for date of service November 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99215 billed for date of service November 4, 2022. 
 
You asked the Plan to pay for code 99215. You say that You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says that the medical records do not support the billing 
of code 99215. The records doesn't support a high level of decision making or the total time required for this 
code. 
 
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 99215 is Office or other outpatient visit for the evaluation and management of an established patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using time for code selection, 4054 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 code 99215. Our reviewer says that code 99215 is supported 
by the medical record. Our reviewer found tThe enrollee was a then 86-year-old man who underwent initial 
consultation with a neurosurgeon on November 4, 2022. The enrollee complained of pain that radiated from his 
buttock down his left lower extremity, accompanied by numbness and paresthesia. The neurological exam was 
was notable for diminished and absent reflexes. Magnetic resonance imaging (MRI) of the spine was reviewed 
and showed L4 foraminal compression bilaterally. It was determined that the enrollee had not exhausted 
conservative management, and he was referred to interventional pain management. The documentation by the 
neurosurgeon supports a medically appropriate history and/or examination and high level of medical decision 
making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99215 have been met. Therefore, we decided that the Plan has to pay for 
code 99215 billed for date of service November 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the records provided support the need 
for a CardioMEMS device. The Plan denied your request. The Plan says the CardioMEMS device has been 
determined to be of uncertain value and carries a risk of significant complications. 
 
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 CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. The CardioMEMS system 
would not be considered medically appropriate and necessary 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 6, 2022, to June 
8, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnosis code N17.9-Acute kidney failure, unspecified is the appropriate primary diagnosis. The Plan denied 
your request. The Plan says the records submitted do not support primary diagnosis code N17.9-Acute kidney 
failure, unspecified. 
 
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 N17.9-Acute kidney failure, unspecified. 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 physician reviewer found there was no clinical or laboratory evidence of acute kidney failure. The 
enrollee's creatinine after treatment with intravenous (IV) fluids was 0.63 at the time of discharge. The review 
has determined that the documentation did not support primary diagnosis code N17.9-Acute kidney failure, 
unspecified.  
 
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 June 6, 2022, to June 8, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tiering exception for Tacrolimus. 
 
You asked the Plan to pre-approve a tiering exception for Tacrolimus. You say that the exception is needed. 
The Plan denied your request. The Plan says the drug does not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tiering exception for Tacrolimus have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tiering exception for Tacrolimus.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Alimta. 
 
You asked the Plan to pre-approve Alimta. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Alimta. Our reviewer says that the 
services are medically necessary. Our physician reviewer found that studies show the chemotherapy 
combination (OPP) has excellent efficacy with acceptable toxicity in previously untreated epidermal growth 
factor receptor (EGFR)-mutated advanced non-squamous non-small cell lung cancer (NSCLC) patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Alimta have been met. Therefore, we decided that the Plan has to pre-approve 
Alimta.  
 
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: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to make additional payment for the hospital services other than the self-
administered drugs. We decided that the Plan does not have to make additional payment for the self-
administered drug provided during the outpatient hospital stay.  
 
You asked the Plan to make additional payment for the outpatient hospital services provided from November 6, 
2022, through November 11, 2022.. You say that you feel more payment should be made. The Plan says that 
the drugs were correctly denied, and the cost sharing was correctly applied to the other services. 
 
We decided that the Plan has to make additional payment for the hospital services other than the self-
administered drugs.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 
 
The enrollee presented to the facility for emergency services due to a fracture. The contract does not clearly 
indicate what cost sharing would apply for the services received. However, we do find that the $90 emergency 
services copayment would be expected for these services. As such, the enrollee should be charged no more than 
$90 for the Medicare Part B covered services. Therefore, we decided that the Plan has to make additional 
payment for the hospital services other than the self-administered drugs.  
 
We also decided that the Plan does not have to make additional payment for the self-administered drug 
provided during the outpatient hospital stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. 
 
The self-administered drugs provided during this hospital stay cannot be covered by Medicare Part B. Separate 
reimbursement can be requested from the Part D plan. Therefore, we decided that the Plan does not have to 
make additional payment for the self-administered drug provided during the outpatient hospital stay. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a pneumatic compressor with calibrated gradient pressure (E0652) 
and related appliances (E0667). 
 
You asked the Plan to pre-approve a pneumatic compressor and related appliances. You say that the records 
provided support that the requested items are medically necessary. The Plan denied your request. The Plan says 
that there is no evidence of a four-week trial of conservative therapy. 
 
The Plan follows Medicare rules. Medicare rules say that PCDs and related appliances are covered when 
certain criteria have been met and when 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 a pneumatic compressor and related 
appliances. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the 
documentation supports the medical necessity of device in question.  The enrollee has a documented history of 
lymphedema with severe swelling and extensive skin changes.  There is satisfactory documentation that the 
edema includes the abdomen.  The enrollee has undergone at least a 4-month trial of compression therapy 
including lymphatic massage and application of compression devices.  There is satisfactory documentation of 
failure of a simpler pneumatic compression device.  The enrollees anatomy does demonstrate unique features 
that would necessitate a segmented device with individual calibration due to the extreme differences in limb 
diameter along their length. There is satisfactory documentation demonstrating the medical necessity of the 
device. 
 
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 pneumatic compressor and related appliances have been met. Therefore, we 
decided that the Plan has to pre-approve a pneumatic compressor with calibrated gradient pressure (E0652) and 
related appliances (E0667).  
 
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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement; however, the documentation does not support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least three (3) visits weekly to regain or maintain her functional status. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that continued SNF care is medically necessary. The 
Plan denied your request. The Plan says you do not meet criteria for SNF approval. 
 
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 and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.