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

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace (L8702).  
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that this device is medically 
necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not 
covered by Medicare B.  
 
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 MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the MyoPro Orthosis is not known to be effective, based on scientific 
evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for this enrollees condition or in widespread use for this enrollees condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 
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 MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on July 21, 2022, July 22, 2022, and July 23, 2022, each billed with code 99222. 
 
You asked the Plan to pay for the EM services as billed. You say that this was billed correctly and should be 
paid. The Plan denied your request. The Plan says the codes are not supported in this case.  
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate 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 problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
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 EM services as billed. Our reviewer says 
that the code for July 21, 2022, is not supported by the records.  Our reviewer found the exam on this date does 
not include a history of present illness or a review of systems. There is no comprehensive history as required 
per coding rules. 
 
For the other two dates of service, the code used is not appropriate as it should only be used for the first 
encounter with the enrollee. There is a more appropriate code for subsequent encounters. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient evaluation and management (EM) services provided on July 21, 
2022, July 22, 2022, and July 23, 2022, each billed with code 99222.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit vision services provided by 
a specialist on September 9, 2022. 
 
You asked the Plan to waive the copayment for the office visit vision services provided by a specialist. You say 
that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for Vision care provided by a specialist.  
 
You have been asked to pay a $40 copayment for vision services provided by a specialist, which is less than the 
contracted $45 copayment amount. This item/service falls within the Vision care benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. 
 
Please note, any denied charges for incorrect billing by your provider is not your responsibility. You are only 
responsible for the $40 copayment for the vision services provided on September 9, 2022. Therefore, we 
decided that the Plan does not have to waive the copayment for the office visit vision services provided by a 
specialist on September 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code J96.21 
rendered from November 28, 2021, to December 4, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
supporting documentation was submitted for reconsideration. The Plan denied your request. The Plan says a 
post-service, post-payment Clinical Validation Audit was performed to ensure that the diagnosis codes on the 
claim supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 754. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with shortness of breath in the setting of known metastatic cancer with 
anasarca. The enrollee was confirmed to have recurrent pleural effusions, for which diuresis was 
provided.  There is no evidence that the enrollee had respiratory failure. As such, the billing of J96.21 is not 
supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis code J96.21 rendered from November 28, 2021, to 
December 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has a chronic stable condition without change. The surgical wound has healed. Education is complete. 
There is no indication for continued skilled nursing services at home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home health services.
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 enrollee requires complex care which 
can be provided at PAM Health. The Plan denied your request. The Plan says the enrollee can receive this care 
in another setting, such as an inpatient rehabilitation facility or in a skilled nursing facility.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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 ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) during sleep as an 
outpatient, for the treatment of obesity hypoventilation syndrome. Medicare does not cover a home ventilator 
for the treatment of obesity hypoventilation syndrome (OHS), or when used at settings that can be provided 
with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee.  
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 
an inpatient rehabilitation facility.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring tests provided on October 25, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for diagnostic services. You say that you are appealing this denial. The Plan denied 
your request. The Plan says this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 remote monitoring tests provided on October 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital evaluation and management (EM) services provided 
on January 25, 2023, with code 99221. 
 
You asked the Plan to pay for the initial EM services as billed. You say that both of these codes should be 
payable.  The Plan denied your request. The Plan says that only the first practitioner to see an enrollee is 
allowed to bill the initial hospital EM code. Since the admitting provider already billed an initial EM code the 
day before, all other visits must be billed as subsequent. 
 
The Plan must follow Medicare rules. Medicare rules say that an initial visit refers to the first time a provider of 
a specific specialty evaluates the enrollee.  
 
We looked at the file and Medicare rules. We find the Plan has misinterpreted the Medicare billing rules in this 
case. The citations used by the Plan are from the American Medical Association (AMA) manual; however, the 
Medicare Claims Processing Manual contradicts this citation. The Medicare manual is considered a higher-
level source and should be deferred to in this case. As this was the first encounter of a provider under 
endocrinology service, reporting the initial code is appropriate. Based on this information, we decided that 
Medicare rules for coverage of the initial EM services as billed have been met. Therefore, we decided that the 
Plan has to pay for the initial hospital evaluation and management (EM) services provided on January 25, 2023, 
with code 99221.  
 
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 pay for inpatient hospital services billed with diagnosis code I50.33 
rendered from April 27, 2022, to April 28, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
supporting documentation was submitted for reconsideration. The Plan denied your request. The Plan says a 
post-service, post-payment Clinical Validation Audit was performed to ensure that the diagnosis codes on the 
claim were supported clinically. 
 
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 diagnosis code I50.33. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that there were no supportive clinical symptoms of acute heart failure including orthopnea, 
paroxysmal nocturnal dyspnea or wheezes. There were no findings of acute heart failure on the physical exam 
such as jugular venous distention, pulmonary rales or third heart sound. The chest x-ray did not reveal any 
pulmonary edema, cardiomegaly or pleural effusions. The enrollee was not treated with intravenous diuretics. 
The review has determined that the documentation did not support diagnosis code I50.33.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis code I50.33 rendered from April 27, 2022, to April 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care billed with code 99223 for date of service 
July 13, 2022. 
 
You asked the Plan to pay for the initial hospital care billed with code 99223. You say that the records provided 
support the services billed.  The Plan denied your request. The Plan says the documents do not support the level 
of care 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and 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 problem(s) requiring 
admission are of high severity. Typically, 70 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 initial hospital care billed with code 99223. Our reviewer 
says that the criteria for coverage have not been met. Our reviewer found the documentation doesnt support 
the CPT code 99223.  The documentation available for review does not support the encounter had the 3 key 
components required to bill the CPT code. 
 
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 initial hospital care billed with code 99223 have not been met. Therefore, 
we decided that the Plan does not have to pay for initial hospital care billed with code 99223 for date of service 
July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo system (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo system. You say that the enrollee's heart failure is 
progressively worsening such that they qualify for the Barostim Neo device to improve symptoms, functional 
capacity and quality of life since she remains symptomatic despite being on maximally tolerated dose of 
medical therapy. The risk of not moving forward with implantation includes further deterioration, 
rehospitalization, and potential heart failure mortality. The Plan denied your request. The Plan says this 
enrollee is a poor candidate for the Barostim device. There is a strong likelihood that her symptoms would not 
improve significantly with the device. Placement of the device is not medically necessary for this 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 pre-approve a Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found Baroreflex stimulation devices have been considered potential alternative treatments 
for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse generator 
implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse 
generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the 
carotid arteries. In August 2019, the FDA approved the system for use in enrollees with refractory heart failure 
who remain symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have 
an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical 
study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved 
cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in enrollee management. As a result, at this 
time the Barostim Neo system would not be considered medically reasonable and necessary in this enrollee's 
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 Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo system (0266T, C1825).