Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the 
enrollee's records do not show ongoing treatments that can only be given in the hospital. When ready to leave 
the hospital, Services needed may be provided safely in a lower 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care provided on November 2, 2021. 
 
You asked the Plan to pay for subsequent observation care. The Plan denied your request. The Plan says the 
claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for subsequent observation care was not filed until March 10, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for subsequent observation care provided on November 2, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the enrollee is not a good candidate for oral 
bisphosphonate due to upper gastrointestinal ulcers. The Plan denied your request. The Plan says the enrollee 
has not tried and failed the preferred drug, zoledronic acid. The reviewer also found that the documentation 
does not support that zoledronic acid would likely be less effective, and/or would likely have adverse effects 
for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria have 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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs,  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cervical facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says  the cervical 
facet joint injections are 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 the injections. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has 
radiculopathy due to cervical spondylosis. According to the LCD, only one to two levels, either unilateral or 
bilateral, are allowed per session and per spine region. The request for treatment at level C4-C5, C5-C6 and 
C6-C7 exceeds the maximum number of levels that can be treated in one session. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the cervical facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 28, 2022, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81334, 81314, 81345, and 
81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 28, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 
81334, 81314, 81345, and 81272.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drugs, Retacrit or Procrit. 
 
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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed one of the preferred drugs, Retacrit or Procrit. The reviewer also 
found that the documentation does not support that Retacrit or Procrit would likely be less effective, and/or 
would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step 
therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service January 10, 2022. 
 
You asked the Plan to pay for code 99285. You say that the medical record documentation supports the billing 
of 99285. The Plan denied your request. The Plan says code 99285 was not supported by the medical record 
and has been down-coded to 99284. Code 99284 is reflective of the services provided based on the medical 
records. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity.  
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 code 99285. Our reviewer says that the Plan was justified in 
down-coding code 99285 to 99284. Our reviewer found the patient presented to the emergency room after 
taking an extra dose of anti-hypertensives. The patient had stable blood pressure and felt fine in the emergency 
room and was discharged. The documentation only supports procedure code 99284, not 99285. The 
documentation reflects a detailed history; a detailed examination; and medical decision making of moderate 
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 code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service January 10, 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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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 presently receiving appropriate services in the acute care setting. 
Continued care in the short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower 
level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility, a skilled nursing 
facility or a long-term care facility.  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 12, 2022, billed with 
codes 81351, 81403, 81404, 81405, 81406, 81407, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 12, 2022, billed with codes 81351, 81403, 81404, 81405, 81406, 81407, 81408 and 81479.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services requested are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional remaining requested therapy is not generally accepted 
as specific and effective therapy for your condition beyond what was approved by the Health Plan. The records 
do not demonstrate that the unique skills of a professional therapist are required to safely and effectively 
provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under 
the supervision of a therapist. The requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. You 
have had ample time for instruction in a home exercise program. You have had extensive therapy and the 
requested additional therapy sessions do not require ongoing skilled professional therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the physical therapy visits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a skin substitute, Artacent ac, per square centimeter (Q4190). 
 
You asked the Plan to pre-approve a skin substitute. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says that the records show that your wound is acute. 
In addition, the records do not show you are receiving standard wound care. The enrollee does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 skin substitute. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested skin substitute is necessary because this is a non-healing wound on the forehead 
where a previous graft has failed. The enrollee meets criteria for approval. 
 
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 skin substitute have been met. Therefore, we decided that the Plan has to pre-
approve a skin substitute, Artacent ac, per square centimeter (Q4190).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neurostimulator electrode implantation procedure. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says that this 
procedure is considered investigational.  
 
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 procedure. Our reviewer says that 
this procedure is considered investigational. Our physician reviewer found that the enrollee takes opioid 
medication to manage their chronic pain related to degenerative disease and diabetic peripheral neuropathy. 
Although a neurostimulator electrode implantation procedure was requested, a review on this specific device 
and procedure does not show sufficient high-quality evidence of safety or effectiveness over standard 
treatments for the enrollee's condition to support this request. Therefore, the requested procedure is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the neurostimulator electrode implantation procedure. 
 
.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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 presently receiving appropriate services in the acute care setting. 
Continued care in the short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower 
level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 
facility.  
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 pay for the durable medical equipment (DME) billed with code 
A9270 for February 21, 2023. 
 
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 are a non-covered. 
 
The Plan must follow Medicare rules. The rules say that A9270, Noncovered item or service, will not be 
accepted under any circumstances for services or items billed to Medicare.  
 
We looked at the file and Medicare rules. The file shows that the services were billed with procedure code 
A9270. This code is for a non-covered service and the file does not show that there was another code that could 
be billed. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) 
billed with code A9270 for February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service February 7, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code A4239 is considered bundled and not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4239 has a status indicator of P on the Physician Fee Schedule. Code A4239 was 
billed as incident to a physician service and is provided on the same day as a physician service, payment for it 
is bundled into the payment for the physician service to which it is incident. This means that procedure code 
A4239 is not separately payable as billed. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4239 billed for date of service February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on March 1, 2023, and billed with codes 87481 and 87798. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on March 1, 2023, and billed with codes 87481 and 87798.