Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary.  
 
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 is medically stable with no acuity and does not need physicians 
supervision 3 times a week in an IRF. There are no acute rehabilitation skilled nursing needs identified or 
documented. The enrollee needs routine physical therapy and occupational therapy and does not need 
specialized intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. The enrollees rehabilitation needs can be provided in an alternate and 
low intensity 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 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 codes 99309 and G8427 for date of service June 9, 2023. 
 
You asked the Plan to pay for codes 99309 and G8427. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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. 
 
 
 We find that CPT codes 99309 and G8427 are not payable as billed. Specifically, these codes were billed with 
modifier HE. Codes billed with modifier HE are not covered and not payable by Medicare. Based on this 
information, we decided that Medicare rules for coverage of codes 99309 and G8427 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 99309 and G8427 for date of service June 9, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 18, 2023, to June 5, 
2023. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. 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 18, 2023. The NOA was not received by the Plan. 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 on May 18, 2023, 
to June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up (D2950) and a mandibular partial 
denture (D5226). 
 
You asked the Plan to pre-approve D2950 and D5226. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says these services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core build-up (D2950) and a mandibular partial denture (D5226).
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 lumbar spine. You say that the requested imaging is 
medically necessary. The Plan denied your request. The Plan says they did not receive any information that 
would allow them to select the specific guideline criteria needed for review of your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 MRI of the lumbar spine have been met. No medical records were submitted to the Plan. Therefore, we decided that the Plan does not have to pre-
approve the MRI of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87481, 87653, 87563, 87640, 87651, 
87551, 87556, 87561, 87500, 87641, and 87801 billed for date of service March 1, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87481, 87653, 87563, 87640, 87651, 87551, 87556, 
87561, 87500, 87641, and 87801. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says payment for codes 87798, 87481, 87653, 87563, 87640, 87651, 87551, 87556, 87561, 
87500, and 87641 are bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that codes 87798, 87481, 87653, 87563, 87640, 87651, 87551, 87556, 87561, 
87500, and 87641 are column II codes to column I code 87801. While these codes were billed with modifier -
59, the medical records provided do not show that the service billed with the -59 modifier is a distinct 
procedural service. Code 87801 is not supported by the documentation. There is a more appropriate lab panel to 
be billed when one or more codes are included in the same panel. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87798, 87481, 87653, 87563, 87640, 87651, 87551, 87556, 87561, 87500, 87641, and 87801 billed for date of 
service March 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 17, 2023, to 
January 18, 2023, 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 is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 J95.2, described as acute 
pulmonary insufficiency following nonthoracic surgery. 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 code. Our physician reviewer found the enrollee is a 79-year-old with intermittent 
claudication was treated in the hospital for 2 days. The documentation provided described the enrollee as 
undergoing a planned right axillary-bifemoral bypass graft procedure requiring intubation. Following 
extubation right after the procedure, the documentation described the enrollee as awake, alert, and oriented x 3, 
tolerating oral, and tolerating low dose oxygen support following reduction in oxygen saturation (88-89%) 
while sleeping in recovery. However, no arterial blood gas measurement was noted as showing hypoxia or 
acute pulmonary insufficiency to objectively confirm and support the diagnosis J95.2. 
 
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 January 17, 2023, to January 18, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) device 
(64555x2). 
 
You asked the Plan to pre-approve a Sprint PNS device. You say that this device will address the enrollee's 
symptoms of chronic knee pain. The Plan denied your request. The Plan says the clinical value and 
effectiveness of the Sprint PNS system in the setting of chronic pain has not been demonstrated in the peer-
reviewed literature. 
 
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 Sprint PNS device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic right knee pain due to osteoarthritis. The use of Sprint PNS 
to treat the pain of knee osteoarthritis is considered experimental and investigational. It is the subject of 
ongoing clinical trials. 
 
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 Sprint PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) device (64555x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each application of a compression system 
provided on June 06, 2023, to June 26, 2023. 
 
You asked the Plan to waive the copayment for each application of a compression system. You say that you 
were unaware of the copayments. 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $300 copayment for each application of a compression system. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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. The total amount you owe 
is $2,100 ($300 copayment x 7 services = $2,100). Therefore, we decided that the Plan does not have to waive 
the copayment for each application of a compression system provided on June 06, 2023, to June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual physical exam provided on April 14, 2023. 
 
You asked the Plan to pay for the annual physical. You say that you did not receive a physical exam at this 
appointment. The Plan denied your request. The Plan says their original decision to deny payment was correct. 
 
The Plan follows Medicare rules. The rules explicitly say that screening services, with the exception of the few 
services listed in the Medicare rules section, are not covered. 
 
The exam at issue in this appeal, the annual physical, was requested solely for screening purposes. The Plan 
covers one annual physical exam per calendar year. The Plan paid for your annual physical exam received on 
June 27, 2023. Therefore, we decided that the Plan does not have to pay for the annual physical exam provided 
on April 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis (L1686) and pelvic control, hip joint, 
adjustable flexion, extension, abduction control, each (L2624) provided May 24, 2023. 
 
You asked the Plan to pay for the orthoses. You say that please review the attached documents and reprocess. 
The Plan denied your request. The Plan says based on Medicare guidelines, the hip orthosis (L1686) and 
accessory (L2624) requested does not meet the requirements for approval. 
 
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 orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that the requested items are being furnished in accordance 
with accepted standards of medical practice for the diagnosis or treatment of the enrollees condition or to 
improve the function of a malformed body member. The documentation does not support that the enrollee 
requires this item for this hip joint. The documentation does not reveal subjective or objective hip complaints, 
hip trauma or surgery, or hip physical exam findings that support the need for this orthosis. 
 
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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for the hip orthosis (L1686) and pelvic control, hip joint, adjustable flexion, extension, abduction 
control, each (L2624) provided May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve MyoPro Motion G. You say that this is medically necessary. The Plan 
denied your request. The Plan says MyoPro is not yet known to be effective. 
 
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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis will improve 
long-term outcomes for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve MyoPro Motion G orthosis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay, cardiac 
ultrasound procedure, office visits and radiology services on August 23, 2022, to April 4, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay, cardiac ultrasound procedure, office 
visits and radiology services. You say that you were unaware that the plan only pays partial per day on hospital 
and leaves the customer with $298.00 per day out-of-pocket 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 $298 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90. You must pay a $100 
copayment for diagnostic procedures and tests at an outpatient hospital. You must pay a $275 copayment 
advanced imaging services at an outpatient hospital. You must pay a $30 copayment for provider and 
professional services at a specialist's office. You must pay a $180 copayment advanced imaging services at a 
specialist's office. Date (s) of service and appealed services: 
 
8/23/2022  8/28/2022  inpatient hospital stay. 
($298.00 x 5 days = $1,490).  
9/08/2022  9/15/2022  inpatient hospital stay. 
($298.00 x 5 days = $1,490).  
10/19/2022  10/21/2022  inpatient hospital stay. 
($298.00 x 2 days = 596). 
10/25/2022  cardiac ultrasound procedure. 
$100 
12/06/2022  12/08/2022  inpatient hospital stay. 
(4298.00 x 2 days = 596). 
12/12/2022  physician visit. 
$30 
12/22/2022- physician visit. 
$30 
12/22/2022- physician visit. 
$30 
12/23/2022  radiology services. 
$109.74 less than the copayment amount. 
02/07/2023  radiology services. 
$23.45 less than the copayment amount. 
04/04/2023  radiology services. 
$23.45 less than the copayment amount. 
 
For all services it's, $1,490 + $1,490 + $596 + $100 + $596 + $30 + $30 + $30 + $109.74 + $23.45 + $23.45 = 
$4,518.64. Therefore, results in the total cost sharing amount of $4,518.64. 
 
You have been asked to pay a $4,518.64 cost share for the inpatient hospital stay, cardiac ultrasound procedure, 
office visits and radiology services. This item/service falls within the inpatient hospital care, outpatient 
diagnostic tests and therapeutic services and supplies, and physician/practitioner services, including doctor's 
office visit 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. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay, 
cardiac ultrasound procedure, office visits and radiology services on August 23, 2022, to April 4, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. 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. 
 
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 Eylea. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the nerve ablation. You say that this procedure is necessary due to the 
failure of conservative treatments to address pain and restore function. The Plan denied your request. The Plan 
says the criteria for coverage have not been met. 
 
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 the nerve ablation. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that basivertebral nerve ablation is considered experimental/investigational and is not 
medically necessary for the treatment of chronic low back pain. 
 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 nerve ablation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve basivertebral nerve ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for an LTACH admission. The Plan denied your request. The Plan says the enrollee is unstable for 
transfer, and the current acute care hospital can provide acute care services until enrollee's condition allows 
transfer to an alternate level of care. 
 
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 is on room air, has no complex wound care needs, and is getting tube 
feeds and a clear liquid diet. Their needs do not arise to the level of LTACH admission. 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 LTACH services.