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

 
We decided that the Plan does not have to pre-approve Avsola. 
 You asked the Plan to pre-approve Avsola. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Avsola. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service 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 Avsola have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avsola.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral airway support appliance (E0486). 
 
You asked the Plan to pre-approve an oral airway support appliance. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that oral appliances are not covered for 
temporomandibular joint (TMJ) or other dental conditions. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an oral airway support appliance have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an oral airway support appliance (E0486).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient discharge management services coded as 99239 
performed on January 6, 2023. 
 You asked the Plan to pay for the inpatient discharge management services. You say that 99239 should be 
covered as billed because it is supported in the record. The Plan denied your request. The Plan says 99239 was 
billed with an inappropriate place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT code 99239 is used for inpatient or 
observation discharge day management services. The rules also say that SNF/NF discharge day management 
services are described by CPT codes 99315-99316. 
 
We looked at the file and Medicare rules. The inpatient discharge management services performed on January 
6, 2023, were billed with place of service 31, indicating the services took place at a SNF. 99239 is appropriate 
for discharge management from inpatient or outpatient hospital only, not for discharge from a SNF.  Based on 
this information, we decided that Medicare rules for coverage of the inpatient discharge management services 
have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient discharge 
management services coded as 99239 performed on January 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord electrical stimulator trial (63650, 95972). 
 
You asked the Plan to pre-approve a spinal cord electrical stimulator trial. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met.  
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless certain 
conditions have been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a spinal cord electrical stimulator trial. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documentation of a multi-discplinary approach and does not have a surgical consultation.  At this 
time, the request is not deemed 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 spinal cord electrical stimulator trial have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a spinal cord electrical stimulator trial (63650, 95972).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77300 billed for date of service February 28, 
2023.   
You asked the Plan to pay for procedure code 77300. You say that 77300 should be covered because all 14 
units billed are supported in the record. The Plan denied your request. The Plan says the billed number of units 
are not supported by the records as both provided and medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 77300 is 10. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE.  
 
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 77300. Our reviewer says that the services at issue in this 
case are not supported by the medical records. Our reviewer found in "step and shoot" or compensator based 
Intensity-modulated radiation therapy (IMRT) treatment courses, 1 unit of 77300 can be charged per gantry 
angle. Therefore, the units of 77300 charged would correspond to the number of gantry angles in the IMRT 
plan, frequently up to 10 units. The provider reported 14 units for procedure with 10 units allowable.  Although 
the procedure report includes more than 10 units of service provided, it does not include documentation of 
rationale for additional units over allowable.  
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 77300 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 77300 billed for date of service February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99204 and J0702 billed for February 24, 
2023. 
 
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 codes 99204 and J0702 are 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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. The definition of code J0702 is injection, betamethasone acetate 3 
mg and betamethasone sodium phosphate 3 mg. 
 
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 codes 99204 
and J0702 are not supported. Our reviewer found the records do not document a medically appropriate history. 
The provided history lacks important information such as past medical history and lacks any information on 
drug allergies or medications taken. Code 99204 is therefore not supported. 
 
The records do not document injection of betamethasone acetate for three milligrams (mg) or betamethasone 
sodium phosphate for three mg. The records document injection of Depo Medrol (methylprednisolone acetate) 
40 mg/1 cc. Code J0702 is therefore not supported. 
 
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 codes 99204 and J0702 billed for February 24, 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 the enrollee does not meet the criteria 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 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305) provided on April 12, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the enrollee does not go to the lab so it 
should not be considered OON. The Plan denied your request. The Plan says this service is not covered when 
provided OON. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (88305) provided on April 
12, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive pharmacogenetics panel (0349U) provided 
April 10, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the test provides valuable information for 
physicians to use in determining the appropriate treatment for their patients. The Plan denied your request. The 
Plan says this testing is considered unproven as the clinical value and effectiveness of comprehensive 
pharmacogenetic testing have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for comprehensive pharmacogenetics panel (0349U) provided April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on September 30, 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 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 supports an appropriate 
exam, but not an appropriate history or a high level of medical decision making. 
 
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 September 30, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for February 26, 2023. 
 
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 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 these services. Our reviewer says that procedure code 99285 
is not supported. Our reviewer found the documentation supports that a comprehensive examination was performed, but not a comprehensive history or medical decision making of high complexity. Procedure code 
99285 is therefore not supported. 
 
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 February 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that a CGM 
is not medically necessary. Our physician reviewer found the enrollee is not on insulin. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88377 billed for date of service November 
14, 2022. 
 You asked the Plan to pay for procedure code(s) 88377. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88377. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88377. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88377 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88377 billed for date of service November 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 22, 2023, billed with 
procedure codes 96365-59, 96366-59 (2 units), 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 documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of codes 96365-59, 96366-59 (2 units), and 96521 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1-hour, intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure), and refilling and maintenance of portable pump. 
 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found codes 96365 and 96366 are not supported 
as the procedure report describes intravenous insulin treatment provided for an outpatient. In this case, a more 
specific code should be reported. Also, 96521 is not supported as procedure report does not include 
documentation of refilling and maintenance of portable pump. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 22, 2023, billed with procedure codes 
96365-59, 96366-59 (2 units), and 96521.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service March 17, 
2023. 
 
You asked the Plan to pay for procedure code 99153. You say that medical records were provided. The Plan 
denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for procedure code 99153 billed for date of service March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided from March 1, 2023, 
to March 29, 2023, by an OON provider.  
 
You asked the Plan to pay for the physical therapy services. You say that you are in-network with the Plan. The 
Plan denied your request. The Plan says these services were not authorized. 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract also says that out-of-network outpatient 
rehabilitation services are not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided from March 
1, 2023, to March 29, 2023, by an OON provider.