Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 20, 2022 to 
August 23, 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 you 
submitted supporting documentation for reconsideration of the DRG adjustment. The Plan denied your request. 
The Plan says a post-service, post-payment clinical validation audit was performed to help 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 DRG 854. 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 pain and decreased urine output. She was found to have an outflow obstruction 
and hydronephrosis.  The enrollee was treated for a presumed urinary tract infection. There is no evidence of 
hypotension, hypoperfusion or organ failure. As such, the billing of A41.9 and R65.20 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 provided on August 20, 2022 to August 23, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an out-of-network provider. The Plan 
denied your request. The Plan says because you are able to see a provider within the Plans network that would 
meet your needs, having care with an in-network provider at an in-network facility would not be detrimental to 
your health; and it is not medically necessary for you to see a primary care physician outside of the network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 9, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
9, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that that you drive large school buses, and the injection 
helps you when you get tired.  The Plan denied your request. The Plan says 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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found that you have not tried and failed the 
required drugs Ferrlecit, Infed, Venofer, and Feraheme. There is no documentation indicating that the Plan's 
requires drugs would likely be less effective or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on 
September 26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 
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 coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support this code as there was evidence of any comprehensive history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99222) rendered on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service April 18, 2021. 
 
You asked the Plan to pay for code 99223. You say that medical records were provided to support payment. 
The Plan denied your request. The Plan says code 99223 billed for date of service April 18, 2021, is not 
supported by the medical record. The medical records don't support a comprehensive history. 
 
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 three key components: a comprehensive history, 
a comprehensive exam, 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 99223. Our reviewer says that code 99223 is not supported by the medical records. Our reviewer found the enrollee was a then, 79-year-old female with a 
history of hypertension, diabetes mellitus, deep vein thrombosis, congestive heart failure with an automatic 
implantable cardioverter defibrillator, hyperlipidemia, and status post abdominal aortic aneurysm repair who 
presented to the emergency room on April 18, 2021, with dizziness. She was evaluated and admitted. 
Procedure code 99223 was not supported for the days of services in question. The code: Initial hospital care, 
per day, for the evaluation and management of a patient, which requires these three key components: 
a comprehensive history, a comprehensive exam, and medical decision making of high complexity. In this case 
there was no comprehensive history documented in the medical record. 
 
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 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service April 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block.  
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says genicular nerve blocks are not covered to treat 
osteoarthritis as this 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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found genicular nerve blocks are considered an experimental therapy and are the 
subject of ongoing clinical trials. Therefore, the request is considered not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced life support (A0433) and ground mileage 
(A0425) provided on June 11, 2022. 
 
You asked the Plan to pay for the advanced life support and ground mileage. You say that you would like this 
claim to be reprocessed as it was improperly denied. The Plan denied your request. The Plan says the 
information provided at the time of the appeal does not support coverage as the enrollee was not transported to 
the closest appropriate facility. 
 
The Plan follows Medicare rules. Medicare rules say that an ambulance transport is covered to the nearest 
appropriate facility to obtain necessary diagnostic and/or therapeutic 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 pay for the advanced life support and ground 
mileage. Our physician reviewer found the destination the enrollee was transported to was requested by family. 
There were closer facilities available. Our reviewer also found that the enrollee was not transported to the 
closest appropriate 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 advanced life support and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for the advanced life support (A0433) and ground mileage (A0425) 
provided on June 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate.  The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre Kit 2 CGM sensor. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested CGM sensor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre Kit 2 CGM sensor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre Kit 2 continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
in bones of spine in lower back, first two bones and heat destruction of intraosseous basivertebral nerve in 
additional bone of spine in lower back (the Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the requested Intracept procedure is considered 
experimental/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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only Modic endplate changes without facet joint disease or foraminal stenosis. The cause of back pain is unclear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion exercise device for use 
other than knee (E0936). 
 
You asked the Plan to pre-approve a continuous passive motion exercise device. The Plan denied your request. 
The Plan says this request does not meet the Medicare or health plan coverage criteria 
 
The Plan must follow Medicare rules. Medicare rules say that continuous passive motion devices are devices 
covered for patients who have received a total knee replacement. 
 
We looked at the file and Medicare rules. The record shows that this device is not being used after a total knee 
replacement, but is being requested for use after a shoulder surgery. Based on this information, we decided that 
Medicare rules for coverage of a continuous passive motion exercise device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous passive motion exercise device for use other 
than knee (E0936).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
January 16, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says for a facility to receive reimbursement for a Medicare 
member, the facility must be enrolled to participate in the Medicare program.  
 The Plan must follow Medicare rules. Medicare says that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Therefore, we decided that the Plan does not have to pay for an emergency department 
visit provided on January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 4, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate.  The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not considered reasonable and necessary in the treatment of lower back pain. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only modic changes without foraminal 
stenosis or facet degenerative joint disease. The cause of the back pain is not clear. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure).