Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70553 and A9579 billed for date of service 
January 27, 2023. 
 
You asked the Plan to pay for procedure codes 70553 and A9579. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says these codes are not supported in the 
medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 70553 and A9579. Our reviewer says that 
these codes are not supported in the records provided. Our reviewer found that, for code 70553, the provider 
performs a magnetic resonance imaging (MRI) study of the brain including the brain stem. He performs this procedure without using contrast material. He then follows with contrast material and takes more images. This 
procedure was not found in documentation and therefore cannot be verified. In addition, the medical record 
does not include sufficient documentation to verify the procedure performed or include the national drug code 
(NDC) number, and therefore code A9579 also cannot be verified. 
 
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 70553 and A9579 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 70553 and A9579 billed for date of service January 27, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous insulin treatment (OIVIT) 
provided on March 16, 2023. 
 
You asked the Plan to pay for the OIVIT services. You say that the requested services should be covered.  The 
Plan denied your request. The Plan says this is not covered by Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is nationally noncovered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the outpatient intravenous insulin treatment 
(OIVIT) provided on March 16, 2023.
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 your current condition requires a SNF admission. 
The Plan denied your request. The Plan says a SNF admission 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 identifiable skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. However, you do not 
require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. Required services can be 
provided at 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the records provided support the need for the requested 
drug. 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 Prolia. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has breast cancer on an 
aromatase inhibitor with expected ongoing bone loss. She is on vitamin D. The Plan requires a trial of drug 
bisphosphonates before they will approve the requested drug. The enrollee has not tried a bisphosphonate. 
There is no documentation of a rationale as to why she cannot take a bisphosphonate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee recently required 
hospitalization for critically elevated carbon dioxide levels and acute chronic respiratory failure. The Plan 
denied your request. The Plan says a home ventilator is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that the records do not show that 
BiPAP with average volume-assured pressure support (AVAPS) has been tried as an outpatient. Medicare does 
not cover a home ventilator for the treatment of obesity hypoventilation syndrome (OHS), or when used at 
settings that can be provided with BiPAP.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a SNF 
admission. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve denosumab.  
 
You asked the Plan to pre-approve denosumab. You say that the enrollee qualifies for the requested drug. You 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
requested drug is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve denosumab. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that although there are indications 
that the enrollee has been intolerant of other medications, we are not told which. Furthermore, the office note 
says that no medications have been used. Although the enrollee clearly needs medications for low bone mineral 
density, we are not told why an oral bisphosphonate or other medications the Plan requires use of or 
contraindication to prior to using Prolia are not options. If the enrollee has tried or has contraindications to the 
other medications required by the Plan, this information should be stated clearly with the medication name and 
when it was used and why it was stopped or never tried. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of denosumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve denosumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-implanted continuous glucose monitor (procedure 
codes A4239 and E2103) provided on April 6, 2023. 
 
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 the records do not support the services billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that durable medical equipment (DME) supplies must be provided with a proof of delivery. 
 
We find that codes A4239 and E2103 are not supported in the medical record. Specifically, the required 
documentation pertaining to the proof of delivery of these supplies was not provided. 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 a non-implanted continuous glucose monitor (procedure codes 
A4239 and E2103) provided on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from March 22, 2023, to March 
29, 2023. 
 
You asked the Plan to pay for the medical services. You say that these are covered services. The Plan denied 
your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that G31.01 has an Excludes1 note in relation to R47.01 and 
G31.01. This means that the two diagnosis codes cannot be reported together. Based on this information, we 
decided that the Medicare billing rules for the medical services have not been met. Therefore, we decided that 
the Plan does not have to pay for medical services provided from March 22, 2023, to March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99221) 
rendered on December 29, 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 Current Procedural Terminology (CPT) code 99221 (1 unit) remains 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 99221 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and Medical decision making that is straightforward or of low 
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 low severity. Typically, 30 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 provided records in this case 
do not include all required elements of a detailed/comprehensive history: a chief complaint, an extended history 
of present illness, a problem pertinent review of systems and a pertinent past, family, and social 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 evaluation and management services (procedure code 99221) rendered on December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
on February 13, 2023. 
 
You asked the Plan to pay for the pathology procedure. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the submitted medical records do not 
contain sufficient detail to support the billed charge. 
 
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 81479 is an unlisted molecular pathology procedure. 
 
 
 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 pathology procedure. Our reviewer says that the 
documentation does not support the service billed. Our reviewer found that the provider reported procedure 
code for test Z01V0, however after review of the laboratory report this procedure was not found and therefore 
cannot be verified. 
 
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 pathology procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted molecular pathology procedure (81479) provided on February 13, 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 IRF services are necessary due to the enrollee's 
impaired functional status and impaired balance. The Plan denied your request. The Plan says the enrollee does 
not meet all the requirments for admission to an IRF.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for COVID-19 testing (U0003, U0005) provided on January 24, 2022. 
 
You asked the Plan to pay for COVID-19 testing. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says that these services are bundled into the payment to the 
facility where the enrollee was admitted at the time. 
 
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. Specifically, there is no evidence to support that the skilled nursing facility 
(SNF) actually performed the laboratory tests at issue, and there is no evidence that the SNF billed these 
services and will make arrangements to pay the other entity internally. As there is no evidence of this, the entity 
that performed the test (the laboratory) may be paid directly. Therefore, we decided that the Plan has to pay for 
COVID-19 testing (U0003, U0005) provided on January 24, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from January 17, 
2023, to February 10, 2023.  
 
You asked the Plan to pay for the home health care services. You say that this claim should be covered at the 
original payment rate. The Plan denied your request. The Plan says the documentation does not support the primary diagnosis on the claim as the chief reason the enrollee required the home health care, and the OASIS 
documentation does not accurately reflect the enrollee's status. 
 
The Plan follows Medicare rules. Medicare rules say that a case mix methodology adjusts the 30-day payment 
rate based on characteristics of the patient and his/her corresponding resource needs (e.g., diagnoses, functional 
impairment level, and other factors). 
 
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 home health care services. Our reviewer 
says that the documentation does not support the diagnosis code billed on the claim. Our physician reviewer 
found that the documentation does not support the correct patient driven payment model (PDPM) health 
insurance prospective payment system (HIPPS) code was submitted by the organization. The documentation 
indicates that the primary diagnosis code was not represented in the clinical documentation received. The 
primary diagnosis code of G62.89 (other specified polyneuropathies) did not appear to be related to the skilled 
services. The partial adjustment to PDGM HIPPS code was appropriate. 
 
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 home health care services have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health care services provided from January 17, 2023, to February 10, 
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 services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting.  
 
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. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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.