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

 
We decided that the Plan does not have to pre-approve Ferumoxytol. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has unspecified iron 
deficiency anemia. She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not 
show that the required drugs would be contraindicated or less effective; therefore, Ferymoxytol is not 
reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ferumoxytol.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, ketorolac tromethamine, per 15 mg rendered on 
March 3, 2022. 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code J1885 (4 Units) 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. 
 
In this case, the CPT Code Manual definition of code J1885 is "Injection, ketorolac tromethamine, per 15 mg." 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 injection. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that after review of the submitted 
records, there is no documentation that Ketorolac (code J1885) was administered to this enrollee. The records 
submitted do not support the use of this code. This review determined that the billed services were 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for injection, ketorolac tromethamine, per 15 mg rendered on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report rendered on 
November 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is covered when 
specific criteria 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
paroxysmal atrial fibrillation, hypertension, hypothyroidism, chronic pain, unspecified peripheral vascular 
disease, and other specified rheumatoid arthritis, as well as others. The office visit note dated December 2, 
2022 documents she is stable on current medications. She is taking multiple medications with no side effects as 
of January 5, 2023. The documentation does not support that the criteria for coverage were met; therefore, the 
testing was not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneDose Genetic Response Report rendered on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99222, 99232, 99239) provided from August 
11, 222, to August 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. 
 
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 codes 99222, 
99232, and 99239, is not supported by the records provided. Our reviewer found that for code 99222, the 
medical records submitted did not support medical decision making of moderate complexity. For code 99232, 
the medical records submitted did support an expanded problem focused interval history or medical decision making of moderate complexity. For code 99239, the submitted discharge summary does not support hospital 
discharge day management of more than 30 minutes was performed. 
 
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 (99222, 99232, 99239) provided from August 11, 222, to August 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you can barely walk, and you won't be able to walk 
at home yourself and you need to gain mobility back with physical therapy and occupational therapy. The Plan 
denied your request. The Plan says the IRF services you and/or your provider are requesting do not meet the 
requirements for approval. 
 
 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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for myocardial infarction and coronary artery bypass grafting. The medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. 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. There is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit (99334) provided on September 05, 2022. 
 
You asked the Plan to pay for a rest home visit (99334). You say that the service should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a rest home visit (99334) 
provided on September 05, 2022.
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 member needs to be relocated as 
soon as possible. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
an IRF admission. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional nerve stimulator (E0770). 
 
You asked the Plan to pre-approve a functional nerve stimulator. You say that you tried using different 
ankle/foot orthosis with only mild improvement in your gait and no improvement in your fall risk. You say that 
you would like to maintain your independence in addition to improve gait by having a NMES. You also say 
that you were evaluation for a NMES and had significant improvement. The Plan denied your request. The Plan 
says a functional nerve stimulator is not covered for diagnosis of foot drop due to peripheral neuropathy. 
 
The Plan follows Medicare rules. Medicare rules say that NMES to treat muscle atrophy is limited to the 
treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and 
peripheral nerves, and other non-neurological reasons for disuse atrophy. 
 
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 functional nerve stimulator. Our 
reviewer says that the requested nerve stimulator is not medically necessary. Our physician reviewer found the 
provided documentation does not indicate the enrollee has a spinal cord atrophy or disuse atrophy where the 
nerve supply to the muscle is intact. Therefore, the reviewer found that the requested nerve stimulator is not 
medically reasonable or 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 a functional nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a functional nerve stimulator (E0770).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) care provided from July 1, 2020, to July 
15, 2020. 
 
You asked the Plan to pay for SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that payment was previously made in accordance with the Medicare Fee 
Schedule so not additional payment is due. 
 
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. The Plan denied payment on the basis that this claim was already paid in 
accordance with the Medicare fee schedule. However, the Plan did not submit evidence that full payment was 
actually made for this SNF stay, nor did the Plan submit any other evidence or rationale to support a denial of 
payment. Therefore, the Plan has not supported that its decision to deny payment for this service is correct or 
justified. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care provided from 
July 1, 2020, to July 15, 2020.  
 
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 the MRI of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI of the lumber spine. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the requested MRI is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI of the lumbar spine. Our 
physician reviewer found that detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. Moreover, there are no objective 
findings of progressive neurologic deficits or any neurological deficits in this case. The enrollee has not had 
any x-rays per the documentation provided. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested diagnostic imaging in this clinical setting. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the MRI of the lumbar spine 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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MRI of the lumbar spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 18, 2022, to 
March 24, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
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 primary diagnosis code A41.9, described as Sepsis, 
unspecified organism, and secondary diagnosis code J96.01, described 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 documentation does not support the billed codes. Our physician 
reviewer found that the enrollee is a 70-year-old female who was treated in the hospital for epistaxis from a 
fall. The provided documentation described the enrollee with upper respiratory congestion but no increased 
pulmonary distress/demand, with normal creatinine, normal platelets, normal bilirubin, oriented x3, and mean 
arterial pressure was intermittently <70 but not consistently (SOFA 1). The patient was treated with low dose 
oxygen support and was diagnosed with pneumonia based on chest X-ray. The enrollee did not require high 
flow oxygen support, bilevel positive airway pressure, or vent support and had no significant respiratory 
distress.  
 
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 March 18, 2022, to March 24, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, chest (71046) provided 
December 8, 2022. 
 
You asked the Plan to pay for the diagnostic service. You say that you have attached medical records to show 
that the service performed was appropriate with the diagnosis code. The Plan denied your request. The Plan 
says the diagnosis is not consistent with the CPT 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 71046 is radiologic examination, chest, 2 views.  
 
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 diagnostic service. Our reviewer says that the Medicare 
criteria for coverage has not been met. Our reviewer found the provider reported CPT 71046: radiologic examination, chest, 2 views with diagnosis Z87.891: personal history of nicotine dependence for service 
provided. The documentation submitted was reviewed and does not meet the criteria. The provider reported a 
"history of" Z87.891 for service provided, which does not support the medical necessity for the service 
provided. The diagnosis code reported, does not directly contribute to the diagnosis and treatment, as this is a 
personal history of diagnosis code Z87.891. 
 
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 diagnostic service have not been met. Therefore, we decided that the Plan 
does not have to pay for the radiologic examination, chest (71046) provided December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided from May 21, 2021, to May 
23, 2021. 
 
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 care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit". 
 
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 submitted medical records include charge 
tickets and progress notes; however, the progress notes do not include the actual dates of service. This means 
the validity and accuracy of the claim cannot be verified. In addition, for those dates of service, there was no 
medical decision making of high complexity. 
 
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 from May 21, 2021, to May 23, 2021.