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. You say that the enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower level of 
care.  
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 pre-approve Hereditary Breast and Ovarian Cancer Risk Panel 
Testing (81432, 81433).  
 
You asked the Plan to pre-approve Hereditary Breast and Ovarian Cancer Risk Panel Testing. You say that this testing is necessary because cancer runs in your family. The Plan denied your request. The Plan says this test is not covered.
 
The Plan must follow Medicare rules. Medicare rules say that this type of test must satisfactory complete a 
MolDX TA. 
 
We looked at the file and Medicare rules. We find that this test has not been approved for coverage based on 
information in the DEX Diagnostic Exchange. Based on this information, we decided that Medicare rules for 
coverage of Hereditary Breast and Ovarian Cancer Risk Panel Testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Hereditary Breast and Ovarian Cancer Risk Panel Testing 
(81432, 81433).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 24, 2023, to 
February 22, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA has been 
submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 24, 2023, to 
February 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has poor mobility wants to return to her 
prior level of function. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Venofer. 
 
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 Feraheme. 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 drug, Venofer. The reviewer also found that 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. 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84436 billed for date of service March 14, 
2023.  
 
You asked the Plan to pay for procedure code 84436. The Plan denied your request. The Plan says payment for 
code 84436 is bundled into payment for code 84439. 
 
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 code 84436 
is a column II code to column I code 84439 with a modifier indicator of 0. The column II code is therefore not payable. 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 code 84436 billed for date of service March 14, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need more therapy to increase your strength. 
The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a 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 a continuation of SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro brace. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is 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 a MyoPro brace. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for the 
enrollee's condition or in widespread use for the enrollee's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro orthosis will improve the long-term outcomes for the enrollee. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 MyoPro brace have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro arm brace (L8702).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on May 16, 2022, to May 19, 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 
medical records support the diagnoses and DRG billed. The Plan denied your request. The Plan says that the 
billed diagnosis of I21.A1 (myocardial infarction type 2) is not supported by the medical record. There is no 
evidence of ischemia-specific symptoms and no new ischemic changes on electrocardiogram (EKG) or cardiac 
imaging. As a result, a lower DRG was paid. 
 
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 a diagnosis of I21.A1 (myocardial infarction type 
2). 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 billed diagnosis of I21.A1 (myocardial infarction type 2) is 
supported by the medical record. Our physician reviewer found the documentation supports a type 2 non-ST-
Elevation Myocardial Infarction (NSTEMI). You do not need EKG changes for this, and troponinemia due to 
demand ischemia is sufficient for the diagnosis which the documentation supports. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on May 16, 2022, to May 19, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi (J0174). 
 
You asked the Plan to pre-approve Leqembi. You say that you strongly believe that Leqembi therapy could 
provide a meaningful therapeutic option to address the enrollee's condition. The Plan denied your request. The 
Plan says because Leqembi has serious side effects it is imperative that the diagnosis be correct. The Plan also 
says in this case, the diagnosis of Alzheimer's disease, although suspected, is unproven, and accordingly, this 
request cannot be safely approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 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 Leqembi. Our reviewer says that 
Leqembi is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested use of Leqembi is not FDA-approved for the enrollees diagnosis. Our reviewer also found that its 
use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare & Medicaid Services (CMS) approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi (J0174).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleep study. 
 
You asked the Plan to pre-approve a sleep study. You say that you need this testing as soon as possible because 
the lack of sleep has been affecting your health. You also say that this test will pinpoint the cause of this, and 
the insomnia has been going on since mid-2020. The Plan denied your request. The Plan says that this request 
is not medically necessary because your records show you do not have an alternative reason for 
polysomnography other than chronic insomnia. 
 
The Plan follows Medicare rules. Medicare rules say that for a diagnosis of obstructive sleep apnea (OSA) to 
be made, the criteria listed in the Medicare rules section of this letter must be met. Medicare rules also say that 
sleep studies and polysomnography are not indicated in the management of chronic insomnia. 
 
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 sleep study. Our reviewer says that if 
the concern is that your chronic insomnia, increased daytime sleepiness, and poor daily function is related to 
undiagnosed OSA, then a sleep study is indicated. Our physician reviewer found given the documentation and 
history, you have risk factors to suggest there could be OSA or related sleep disorders. Our reviewer found that 
therefore, it is reasonable to perform a sleep study for further diagnosis and potentially management. 
 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 sleep study have been met. Therefore, we decided that the Plan has to pre-
approve a sleep study.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for October 8, 2022. 
 
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 procedure code 99285 is not supported. 
 
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. 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.  
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 these services. Our reviewer says that procedure code 99285 
is not supported. Our reviewer found the enrollee presented to the emergency department with multiple 
complaints, including bilateral knee pain for months. There is no history of present illness, but rather a list of 
historic items and observations. The medical decision making is not of high complexity. The illness itself did 
not pose an immediate threat to life or function. Code 99285 is not supported by the submitted records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99285 billed for October 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on October 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 a medically appropriate history and/or examination and high level 
of medical decision making". 
 
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 use of code 99285 is 
not supported by the records provided. Our reviewer found that the history and examination are not comprehensive. The medical decision making is not of high complexity. The condition itself did not pose an 
immediate threat to life. 
 
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 the services (99285) provided on October 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on February 17, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 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". 
 
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 use of code 99223 is not supported by the records provided. Our reviewer found that the documentation does not reflect a medically 
appropriate history, exam, and high level of medical decision making, or at least 75 minutes of time spent. 
 
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 the services (99223) provided on February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service May 3, 2022. 
 You asked the Plan to pay for procedure code 99221. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for procedure code 99221 is bundled into 
payment for code 11044. 
 
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 code 99221 is a column II code to column I code 11044; however, 99221 
was billed with a modifier.  
 
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 code 99221. Our reviewer says that procedure 
code 99221 does not meet criteria for payment. Our reviewer found that the provided procedure report 
documents an evaluation and management service was provided for evaluation of grade 4 sacral ulcer, and a 
procedure was performed. In this case, modifier 25 (indicating a significant, separately identifiable evaluation 
and management service by the same physician or other qualified health care professional on the same day of 
the procedure or other service) cannot be verified, as the evaluation and management service is related to the 
procedure performed. 
 
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 code 99221 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99221 billed for date of service May 3, 2022.