Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Saphnelo. 
 You asked the Plan to pre-approve Saphnelo. You say that the enrollee has been treated in the past with both 
Plaquenil and Skyrizi without a positive clinical response. The Plan denied your request. The Plan says that the 
step therapy requirements 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 Saphnelo. Our reviewer says that 
Saphnelo is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drug Benlysta. Also, there is no indication that the Plan's required drug would likely be less 
effective or likely have adverse effects for the 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 Saphnelo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Saphnelo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3000).  
 
You asked the Plan to pay for foot orthotics. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item is not on a shoe that is an integral part of a covered brace. 
 
Medicare rules state that shoes, inserts, and modifications are covered in limited circumstances. They are 
covered in selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. However, different codes are used for footwear provided under this benefit. Inserts and other shoe modifications (L3000) 
are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary 
for the proper functioning of the brace. The Plan follows these same rules.   
 
This item is not on a shoe that is an integral part of a covered brace. Therefore, we decided that the Plan does 
not have to pay for foot orthotics (L3000).
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 services are medically necessary for 
the enrollee who is at high risk for a poor outcome if not provided the level of care needed. The Plan denied 
your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable 
for transfer to an LTACH. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222-57 billed for date of service October 
19, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the billed service cannot be verified. 
 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 code 99222-57 is not supported in the medical record. Specifically, the medical records 
provided do not include an evaluation and management service. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99222-57 billed for date of service October 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRA of the brain. 
 
You asked the Plan to pre-approve an MRA of the brain. You say that an MRA of the brain is medically 
necessary. The Plan denied your request. The Plan says the provider did not provide documentation as to the 
degree for relatedness of family history and there is no other indication for performing this study. 
 
The Plan follows Medicare rules. Medicare rules say that an MRA of the brain is covered when the criteria 
listed in the Medicare rules section of this decision are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRA of the brain. Our reviewer 
says that the requested MRA is not considered medically necessary in this case. Our physician reviewer found 
that during the encounter of May 30, 2023, the enrollee was asymptomatic. There is a notation of family history 
of intracerebral aneurysm but no details as to whether the history relates to a first degree relative or 
other. While MRA is indicated for a strong family history of intracerebral aneurysm, the medical necessity of 
the requested MRA cannot be established without family history details. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRA of the brain.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says that admission to an IRF does not meet criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found per Medicare Benefit Policy Manual Ch 1, 110, and 42 CFR 412.622, the medical record overall 
significantly complies with the various documentation requirements for IRF admission (e.g., as best 
summarized by the medical doctor (MD) and occupational therapist (OT) notes from August 9, 2023). Indeed, 
this enrollee's condition is in fact complex and fragile, and there is every reason to expect that she will 
participate in and benefit from services to include at minimum physical therapy (PT), occupational therapy 
(OT), speech-language pathologist (SLP) follow-up, physician oversight of polypharmacy and infection risks, 
and case manager coordination of any additional services she might need to make a sustainable return home / 
avoid an otherwise preventable readmission to the acute hospital. Therefore, the requested inpatient rehab 
facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness (E2313), expandable controller (E2377), and 
positioning belt/safety belt/pelvic strap (E0978). 
 
  You asked the Plan to pre-approve a harness, expandable controller, and positioning belt/safety belt/pelvic 
strap. You say that a group 3 power wheelchair is based on condition, not suspension but the home assessment 
shows the patient's flooring changes from laminate to carpet. You also say that Medicare approved all codes, 
and it is to your understanding that the Plan follows Medicare's guidelines. The Plan denied your request. The 
Plan says codes E2377 and E2313 cannot be covered. The Plan also says a seat belt is already included with the 
power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 harness, expandable controller, and 
positioning belt/safety belt/pelvic strap. Our reviewer says that the requested electrical accessories are not 
medically necessary as the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. Our reviewer also found that there is a seat 
belt included in the authorized power wheelchair. 
 
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 harness, expandable controller, and positioning belt/safety belt/pelvic strap 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a harness (E2313), 
expandable controller (E2377), and positioning belt/safety belt/pelvic strap (E0978).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service January 25, 2023, to 
February 23, 2023. 
 
You asked the Plan to pay for the billed services. You say that the NOA was 2 days late. The Plan denied your 
request. The Plan says that the NOA was not received by the Plan. 
 
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. 
 
We looked at the file and the rules. The file shows that the provider submitted an NOA on January 30, 2023, 
that was rejected by the Plan. The records show that the provider submitted an NOA that was acknowledged by 
the Plan on February 9, 2023. The records do not show whether this NOA was rejected or accepted by the Plan. 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Therefore, we decided that the Plan has to pay for the home health care billed 
for dates of service January 25, 2023, to February 23, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for date of service 
October 25, 2022. 
 You asked the Plan to pay for procedure codes 88342 and 88341. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 88342 and 88341 is bundled into 
payment for codes 88360 and 88361. 
 
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, we have confirmed that codes 
88342 and 88341 are column II codes to column I codes 88360 and 88361. This claim has not been billed with 
an appropriate modifier to bypass the edit. 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 88342 and 88341 billed 
for date of service October 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 1, 2022, to 
November 30, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the NOA for these 
services. 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 September 2, 2022. The NOA was not received by the Plan until December 
20, 2022. 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 
from November 1, 2022, to November 30, 2022.
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 March 3, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you disagree with the 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. This means that 
procedure code A4239 is bundled/excluded. 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 March 3, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284) provided on February 6, 
2023. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 17, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the emergency room services have not been 
met. Therefore, we decided that the Plan does not have to pay for emergency room services (99284) provided 
on February 6, 2023.
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  that the enrollee would benefit from 
admitting into the LTACH for continuation of intravenous line (IV) antibiotics, lab monitoring, wound care, 
physical therapy, and occupational therapy under the guidance of their attending physicians.  The Plan denied 
your request. The Plan says an LTACH admission is not medically necessary.  
 
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 improving and only requires short-term acute care at the current 
facility until more 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. 
 
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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 27, 2023, to 
February 25, 2023. 
 You asked the Plan to pay for the home health services. You say that authorization was not required for these 
services. 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 December 28, 2022. The NOA was not received by the Plan until March 7, 
2023. 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 
from January 27, 2023, to February 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 3, 2022, to 
November 8, 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 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 J96.91, described as 
respiratory failure, unspecified 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 code. Our physician reviewer found that the enrollee is a 91-year-old female who was treated in the 
hospital. She presented with cough and palpitations and was found to have pneumonia based on imaging. 
Antibiotics and low-dose oxygen support (2-3L/m) were started and continued. The records did not describe 
the enrollee ever needing high flow oxygen, bilevel positive airway pressure, or vent support for her condition. 
There was no arterial blood gas measurement to confirm respiratory failure and oxygen saturation was stable 
on low dose oxygen only with the patient not in acute distress. Therefore, diagnosis code J96.91 is not 
sufficiently supported in the provided documented.   
 
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 November 3, 2022, to November 8, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 11, 2022, to 
November 2, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim denied in error as it was billed 
correctly. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 11, 2022. The NOA was not received by the Plan until January 9, 
2023. 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 
from October 11, 2022, to November 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service November 
18, 2022, to December 17, 2022. You asked the Plan to pay for the billed services. You say that no definitive reason for denial was given. The 
Plan denied your request. The Plan says the NOA was not received timely. 
 
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 September 19, 2022. The NOA was not received by the Plan until 
December 21, 2022. 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 the home 
health care billed for dates of service November 18, 2022, to December 17, 2022.