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

 
We decided that the Plan does not have to pre-approve Renflexis. 
 You asked the Plan to pre-approve Renflexis. The Plan denied your request. The Plan says 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 Renflexis. Our reviewer says that 
Renflexis is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee 
has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's 
required drug(s) would likely be less effective and/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 Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 11, 2023, billed with 
codes 87481, 87482, 87500, 87640, 87652 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 11, 2023, billed with codes 87481, 87482, 87500, 87640, 87652 and 87798.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee in currently in the inpatient of 
rehabilitation and does not have anywhere to go and needing extended care. The Plan denied your request. The 
Plan says services does not meet Medicare guidelines; the enrollee is receiving adequate and necessary 
intensive rehabilitation in the Inpatient Rehabilitation Facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on February 27, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the service should be covered. The Plan denied 
your request. The Plan says this provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy provided on February 
27, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99223, 99239) provided on January 26, 2023, and January 
27, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the claim has been 
billed incorrectly as the billed codes are for inpatient services with an outpatient place of service. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the claim has been billed incorrectly as the billed codes are 
for inpatient services with an outpatient place of service. The definition of code 99223 is "Initial hospital 
inpatient or observation care, per day, for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 75 minutes must be met or exceeded". The definition of 
code 99239 is "Hospital inpatient or observation discharge day management; more than 30 minutes on the date 
of the encounter". As both of these codes can be used for inpatient or observation care, the Plan's denial cannot 
be substantiated. Therefore, we decided that the Plan has to pay for the services (99223, 99239) provided on 
January 26, 2023, and January 27, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for dates of service April 12, 
2023, and April 13, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the level of care 
billed. The Plan denied your request. The Plan says the billed code 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. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
 We find that CPT code 99233 is not supported in the medical record. The records show that the enrollee was 
seen for hip pain and was treated with medication. The records do not show that a high level of medical 
decision making was provided. The records do not indicate the amount of time spent with the enrollee. 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 99233 billed for dates of service 
April 12, 2023, and April 13, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99291 and 36556 provided on December 10, 2022. 
 
You asked the Plan to pay for procedure codes 99291 and 36556. You say that the medical records support the 
billing of codes 99291 and 36556. The Plan denied your request. The Plan says that the medical records do not 
support the billing of codes 99291 and 36556. 
 
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. The definition of code 36556 is Insertion of non-tunneled centrally inserted central venous 
catheter; age 5 years or older. 
 
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 procedure codes 99291 and 36556. Our reviewer says that 
the medical records support the billing of codes 99291 and 36556. Our reviewer found there is clear 
documentation of critical care time, with 35 minutes documented. There was clear documentation of central 
line placement. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99291 and 36556 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 99291 and 36556 provided on December 10, 2022.  
 
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 pay for the services (26750) provided on January 28, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code was billed 
without the appropriate modifier. 
 
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 payment for CPT code 26750 is not supported in the medical record. Specifically, code 26750 was 
not billed with the appropriate anatomical modifier. 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 the 
services (26750) provided on January 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that the enrollee 
needs the requested device due to chronic lymphedema. The Plan denied your request. The Plan says there is 
no documentation that the enrollee's lymphedema extends past her legs. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services coded as 78803 performed on date of service 
February 17, 2023.  
 
You asked the Plan to pay for 78803. You say that 78803 should be covered as billed because it is supported in 
the documentation and was billed with an appropriate modifier. The Plan denied your request. The Plan says 
that 78803 is not eligible for separate payment because it is bundled into payment for code 79445. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The case file did not include proof that code 79445 was billed for date of service 
February 17, 2023, by the same provider who performed code 78803. Without documentation showing 79445 
was billed by the same provider for the same date of service, we cannot confirm whether the Plans rationale 
was correct in denying 78803. Therefore, we decided that the Plan has to pay for the radiology services coded 
as 78803 performed on date of service February 17, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 7, 2022, to 
December 1, 2022. 
 You asked the Plan to pay for the home health services. You say that the NOA was filed on January 19, 2023, 
and you believe this is timely. 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 November 7, 2022. The NOA was not received by the Plan until January 
20, 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 November 7, 2022, to December 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that medical necessity is supported for this procedure. 
The Plan denied your request. The Plan says this has not been shown to be safe and effective, and the enrollee 
has contraindications to the procedure. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on April 25, 2023. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the records do not 
contain an order for the tests performed in the custom panel. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the specific testing provided in this case. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing provided on April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on December 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81455) provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 6, 2023, billed with 
procedure codes 96365-59, 96366-59, and 96521. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT 
regimen. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. The service is question is not payable as it is 
a non-covered service. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on April 6, 2023, billed with procedure codes 96365-59, 96366-59, and 96521.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that this facility has the proper equipment to 
meet your medical needs. The Plan denied your request. The Plan says the requested services are not medically 
reasonable and 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 you do not require skilled rehab at a tertiary level of care. You can 
continue to receive outpatient skilled rehab services for the treatment of your condition. 
 
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 physical therapy (PT) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy home health visits 
(G0151). 
 
You asked the Plan to pre-approve the aide services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 aide services. Our physician 
reviewer found that the enrollee does not have documented, ongoing, home health physical therapy needs. The 
requested care 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 the aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional physical therapy home health visits (G0151).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 22, 2022, to 
October 21, 2022. 
 You asked the Plan to pay for the home health services. You say that the NOA is on file as of November 17, 
2022. 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 August 23, 2022. The NOA was not received by the Plan until November 
17, 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 September 22, 2022, to October 21, 2022.