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

 
We decided that the Plan does not have to pay for a total hip arthroplasty with computer assisted surgical 
navigation provided on December 20, 2022. 
 
You asked the Plan to pay for a total hip arthroplasty. You say that this procedure was medically necessary for 
the enrollee. The Plan denied your request. The Plan says the documentation submitted provides no additional 
information that justifies this request for computer guidance surgery. 
 
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 a total hip arthroplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. There are no diagnostic imaging 
studies provided to corroborate left hip pathology. 
 
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 total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pay for a total hip arthroplasty with computer assisted surgical navigation provided on 
December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (procedure code G0483) 
rendered on March 23, 2023. 
 
You asked the Plan to pay for the testing. 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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support why drug testing for 22+ drug classes was 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive urine drug testing (procedure code G0483) rendered on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on November 7, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the telehealth services. You say that the services should be covered. The Plan 
denied your request. The Plan says telehealth services are not covered when obtained out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the telehealth services provided on November 7, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 38 units of procedure code 00142 rendered on September 14, 
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 the records do not support the number of units billed. 
 
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 00142 is "Anesthesia for procedures on eye; lens 
surgery." 
 
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 anesthesia time billed was 
11:57-12:34. In this case, the anesthesia billing code CPT 00142-QZ-QS-P3 (billed as 38 units) was denied. 
Time units are computed by dividing the reported anesthesia time by 15 minutes (in this case: 37 minutes/15 
minutes = 2.47 units). CPT 00142 has 4 Base units. Base units + Time units = 4 + 2.47 = 6.47 total units. This 
number of units would then be multiplied by the conversion factor and any appropriate modifier. The submitted 
anesthesiology bill of 38 units is not supported in this case. 
 
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 38 units of procedure code 00142 rendered on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the enrollee needs 
an electric hospital bed with an alternating pressure mattress. The Plan denied your request. The Plan says this 
request is considered not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered if the beneficiary 
meets at least one of the three criteria listed in the Medicare rules section of this letter. 
 
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 powered pressure-reducing air 
mattress. Our reviewer says that a powered pressure reducing air mattress (E0277) is not medically necessary. 
Our physician reviewer found the enrollee has impaired ability to perform daily activities and mobility due to 
back pain. However, the enrollee is noted to have nearly full motor strength and it is not clear why they cannot 
independently preform pressure relief in bed. Our reviewer also found that the enrollee does not have a history 
of pressure wounds. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1851). 
 
You asked the Plan to pre-approve a knee orthosis. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a knee orthosis. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not have recent injury, surgery or knee instability. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1851).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99239. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 99222.  
 
You asked the Plan to pay for Practitioner services provided on October 23, 2022, billed with procedure codes 
99222 and 99239. You say that the claim is billed correctly and should be paid. The Plan says that the billed 
units exceed the allowed amount. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99239.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99239.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99222. 
 
 The Plan follows 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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99222 have not been met. In this case, the MUE for 
CPT code 99222 is 1. The MAI value for this code is 3. You billed 2 units of this code, exceeding the MUE. 
You did not provide all the required evidence showing that the excess units were actually provided, were 
correctly coded, and were medically necessary. Therefore, we decided that the Plan does not have to pay for the 
services described by procedure code(s) 99222. 
 
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 you are requesting an expedited appeal for the denial 
of an IRF admission. You say the enrollee was independent and active before coming to the hospital and 
wishes to return to being independent as quickly as possible. The Plan denied your request. The Plan says the 
enrollee does not meet the medical criteria for an IRF admission. 
 
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 the enrollee's 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 and/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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 8, 2022, to 
December 6, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe this NOA 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 October 8, 2022. The NOA was not received by the Plan until February 3, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Please note that you only provided evidence that a claim was submitted timely, not the 
required NOA. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 8, 2022, to December 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 4, 2023, to 
January 26, 2023. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received. 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. 
 
In this case, there is no evidence to support that the NOA was received by the Plan. 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 
January 4, 2023, to January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140) and the panoramic radiographic 
image (D0330) provided by an out-of-network provider on March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that when you checked the provider was in-network. 
The Plan denied your request. The Plan says that the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied the dental services because they were provided by 
an out-of-network provider while citing that the Evidence of Coverage (EOC) only states that the services are 
only covered when provided by an in-network provider. We requested the proper EOC for the year of 2023, but 
it was never received. Without the EOC for 2023, the Plan has not sustained their denial reason for the dental 
services. Therefore, we decided that the Plan has to pay for a limited oral evaluation (D0140) and the 
panoramic radiographic image (D0330) provided by an out-of-network provider on March 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA). 
 
You asked the Plan to pre-approve an MRA. You say that an MRA is medically necessary. The Plan denied 
your request. The Plan says the requested MRA does not meet the Medicare coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that an MRA is covered when the criteria listed in the 
Medicare rules section of this decision are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRA. Our reviewer says that the 
requested MRA is not considered medically necessary in this case. Our physician reviewer found that an MRA 
of the brain has been requested but the submitted records show no clinical indication for the examination.   
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRA.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT). 
 
You asked the Plan to pre-approve the TTFT. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that TTFT is covered for the indications established in the 
applicable LCD. 
 
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 TTFT. Our reviewer says that TTFT 
is not medically reasonable and necessary in this case. Our physician reviewer found that for this enrollee, it 
would be difficult to claim that the treatment would be effective, as it is not being offered in the upfront setting, 
nor is it clear if it will be offered in conjunction with chemotherapy. There may be no other viable treatment 
options for this enrollee who has already received standard chemotherapy after resection, and the after 
recurrence, immunotherapy (which needed to be discontinued due to life-threatening toxicity), radiotherapy 
and more chemotherapy, though subsequent salvage systemic options (listed in NCCN guidelines under the 
PRINCIPLES OF SYSTEMIC THERAPY would be standard of care. It is not evident that the patient could 
not undergo these standard therapies. The LCD criteria are not met, and therefore TTFT is not medically 
reasonable and 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 TTFT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve tumor treatment field therapy (TTFT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on October 9, 2022, 
to October 19, 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 the 
diagnosis code and DRG assignment is supported as billed. The Plan denied your request. The Plan says the 
review did not find sufficient documentation to clinically validate the diagnosis of J96.01. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, J96.01, defined as Acute 
respiratory failure with hypoxia. 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 submitted DRG is not supported. Our 
physician reviewer found while the enrollee had a pleural effusion, there is no documentation that they had 
acute respiratory failure with hypoxia, so the code J96.01 is not justified.  
 
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 the inpatient hospital services provided on October 9, 2022, to October 19, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says  the enrollee is not injecting insulin three times a day. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that a CGM 
is not medically necessary. Our physician reviewer found the enrollee is not taking insulin. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).