Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you disagree with the denied claim.  The Plan 
denied your request. The Plan says this plan covers up to 100 days per benefit period for SNF. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) provided on March 21, 
2023. You asked the Plan to pay for the dental service. You say that you were advised that the dental service would 
be 100% covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because there was no tooth number submitted with the claim for the resin-based composite. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the dental service have been met. 
Specifically, the notice of denial of payment was issued on July 25, 2023, stating that you needed to submit the 
required tooth number for the resin-based composite and without a valid tooth number the claim could not be 
paid. Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2392) provided 
on March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service September 
22, 2022.  
 
You asked the Plan to pay for procedure code 88374. You say that the documentation supports the testing. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation does not show why the excess units were needed. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
February 7, 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 ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in 
clinical management exceeds the needs of the enrollee. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee had extensive drug testing performed. This testing for 22+ drug classes was not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0483) rendered on February 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport received on March 10, 
2023. 
 
You asked the Plan to pay for ambulance services without transport. You say that without transport you should 
not have to pay the amount that you are being billed. The Plan denied your request. The Plan says without a 
transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 10, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services without transport received on 
March 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and Dexamethasone Sodium Phosphate. 
 
You asked the Plan to pre-approve Keytruda and Dexamethasone Sodium Phosphate. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested drugs are not 
medically necessary. 
 
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 Keytruda and Dexamethasone Sodium 
Phosphate. Our reviewer says that the documentation does not support that the requested drugs are medically 
reasonable or necessary. Our physician reviewer found the enrollee has stage 3b high grade papillary serous ovarian cancer. The Food and Drug Administration has not stated that the requested drugs are indicated for the 
enrollee's specific condition. The Medicare approved cancer drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's specific clinical situation. Therefore, the enrollee does 
not meet criteria for the requested drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda and Dexamethasone Sodium Phosphate have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Keytruda and Dexamethasone Sodium Phosphate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937 billed for date of service March 23, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the coding 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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure). 
 We find that CPT code 76937 is not supported in the medical record. The records do not show that the required 
services described by the billed code was provided. 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 procedure code 76937 billed for date of service March 23, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on September 22, 2022, to 
September 27, 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 G93.41 
is supported in the documentation, therefore the claim should be paid at the original DRG. The Plan denied 
your request. The Plan says that G93.41 is not supported in the documentation. 
 
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 G93.41, defined as metabolic 
encephalopathy. 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 secondary diagnosis of G93.41 is supported in the 
documentation. Our physician reviewer found records show the enrollee had advanced dementia and an acute 
change. The enrollee was inattentive chronically but had an acute change with evidence of hypernatremia, so 
they had an acute on chronic change in mental status with a metabolic cause. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on September 22, 2022, to September 27, 2022, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service May 17, 
2023. 
 
You asked the Plan to pay for procedure code 77062. You say that 77062 should be paid as billed because it is 
a valid procedure code performed on this date of service. The Plan denied your request. The Plan says the 
billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service May 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep brain stimulation. 
 
You asked the Plan to pre-approve deep brain stimulation. You say that the enrollee would benefit from this 
procedure. The Plan denied your request. The Plan says the enrollee does not meet the medical criteria for this 
procedure. 
 
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 deep brain stimulation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of essential tremor. The record 
documents active treatment for depression and bipolar disorder. The diagnosis of depression is an exclusion for 
coverage under the rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of deep brain stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve deep brain stimulation.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox.  
You asked the Plan to pre-approve Botox. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Botox. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of cervical dystonia. The documentation does not support that the enrollee 
has tried and failed Dysport or Xeomin. The documentation does not support that Dysport or Xeomin would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on March 4, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded". 
 
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 99223 is not supported by the records provided. Our reviewer found that the medical decision making is not of high 
complexity. As such, the billing of code 99223 is not supported. 
 
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 (99223) provided on March 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on April 7, 2023, and April 8, 
2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
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 99233 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded". 
 
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 99233 is 
not supported by the records provided. Our reviewer found that the documentation supports an appropriate 
exam, but not an appropriate history or medical decision-making of a high level on the dates in question. 
 
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 (99233) provided on April 7, 2023, and April 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 5, 2022, to 
September 3, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was filed timely. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 6, 2022. The NOA was not received by the Plan until December 8, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 5, 2022, to September 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 23, 2022, to June 3, 
2022. 
 You asked the Plan to pay for the home health services. You say that the NOA was originally sent timely. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 23, 2022. The NOA was not received by the Plan until July 11, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
May 23, 2022, to June 3, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the continued skilled nursing facility (SNF) care provided from March 
3, 2023, to April 1, 2023. 
 
You asked the Plan to pay for the continued SNF care. You say that the continued SNF care should be paid for 
under the Medicare Act.  The Plan denied your request. The Plan says that the enrollee did not meet the criteria 
for continued SNF care. 
 
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 pay for continued SNF care. Our reviewer says that 
the requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee had a heel wound and may have been on IV antibiotics, which would 
have been a skilled nursing need.  There is sufficient information to indicate that the health plan did have SNF 
records.  As these records have not been provided to the IRE for review, the health plan has not supported its 
denial.  The health plans denial should be overturned. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have been met. The Plan must continue coverage for the 
SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been 
issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for the 
continued skilled nursing facility (SNF) care provided from March 3, 2023, to April 1, 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.