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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that denying IRF services will prolong the hospital care. 
The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest and 
abdomen. 
 
You asked the Plan to pre-approve a CT scan. You say that the enrollee has a history of hepatocellular 
carcinoma, and the surveillance CT scan was due in January. The Plan denied your request. The Plan says the 
request does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the recommended screening and 
surveillance imaging method for hepatocellular cancer is ultrasound, and the recommended interval is every 
six months. Therefore, the requested CT scan is not medically reasonable or 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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan of the chest and abdomen.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting reconsideration stating 
Trulicity is medically necessary for the enrollee's treatment and is a continuation of therapy. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure code 99223 and 99233) rendered 
from September 17, 2022, to September 18, 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 the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 99223: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are 
spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; 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 patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 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 notes did not describe the 
enrollee as unstable or complex and there was no evidence of medical decision-making of high complexity for 
either date. Additionally, the documentation described history of the patient being asymptomatic without events 
and were brief and focused, not detailed or comprehensive. Therefore, there was insufficient support made for 
codes, 99223 or 99233 as the criteria were not met.  
 
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 hospital care (procedure code 99223 and 99233) rendered from September 17, 2022, to 
September 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 You asked the Plan to pre-approve ESI. You say that the enrollee's health is in jeopardy and is in continuous 
pain. The Plan denied your request. The Plan says the records do not show the enrollee has failed to respond to 
4 weeks of non-invasive conservative care. 
 
The Plan follows Medicare rules. Medicare rules state that epidural steroid injections may be covered if certain 
criteria are 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 ESI. Our reviewer says that the enrollee 
does not meet criteria for this procedure. Our physician reviewer found there is no documentation of recent 
physical therapy, chiropractic therapy, a home exercise program, or documentation of other medication trials. 
Therefore, the request does not meet the criteria of conservative therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), brain (including 
brain stem); without contrast material (70553), Magnetic resonance imaging (MRI), orbit, face, and/or neck; 
without contrast material(s), followed by contrast material(s) and further sequences (70543), and computed 
tomography (CT), orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material 
(70480) to be provided at an out-of-network facility. 
 
You asked the Plan to pre-approve the imaging services. You say that your doctor recommended you go to this 
facility. You say that they advised you would get in and have results quicker if you go there. You also say that 
your doctor is trying to save your life. The Plan denied your request. The Plan says the requested procedure can 
be provided in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 imaging services. Our reviewer says 
that the imaging services to be provided at an out-of-network facility are not medically necessary. Our 
physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to 
meet your medical needs through a referral to a network provider. The reviewer found there is nothing unique 
about your condition that that would make it medically necessary for you to see the requested out-of-network 
provider. Therefore, the reviewer found that the requested services can be provided 
 
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 imaging services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI), brain (including brain stem); without 
contrast material (70553), Magnetic resonance imaging (MRI), orbit, face, and/or neck; without contrast 
material(s), followed by contrast material(s) and further sequences (70543), and computed tomography (CT), 
orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material (70480) to be provided at 
an out-of-network facility.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 2, 2022, to 
April 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you do not believe that the admit 
dates on the claim and the NOA have to match. 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 April 2, 2022, to April 
27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supply allowance (K0553) 
provided on December 1, 2022. 
 
You asked the Plan to pay for the supply allowance. The Plan denied your request. The Plan says the benefit 
limit has been reached and this is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the supply allowance (code K0553 or A4238) is 
billed as one (1) unit of service (UOS) per thirty (30) days. Only one (1) UOS of code K0553 or A4238 may be 
billed to the DME MACs at a time. Billing more than one (1) UOS per thirty (30) days of code K0553 or 
A4238 will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. The records show that a supply allowance was billed and paid by the 
Plan for November 3, 2022. The requested supplies were billed less than 30 days later. As only one unit of code 
K0553 is billable every 30 days, the requested supplies are not payable. Based on this information, we decided that Medicare rules for coverage of the supply allowance have not been met. Therefore, we decided that the 
Plan does not have to pay for the continuous glucose monitor supply allowance (K0553) provided on 
December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not reveal objective cervical imaging studies to correlate with your exam and symptoms. The 
documentation does not reveal failure of noninvasive conservative care for four weeks (i.e. physical therapy) 
for the cervical spine. The coverage 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on December 22, 
2022, billed with codes 87798 and 87541. 
 
You asked the Plan to pay for the respiratory pathogen panel. You say that this testing was medically necessary 
and is supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory pathogen panel have not been met. Specifically, the records show that this was a 
single panel which was unbundled and reported with multiple codes. Therefore, we decided that the Plan does 
not have to pay for the respiratory pathogen panel provided on December 22, 2022, billed with codes 87798 
and 87541.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) with an oncologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that there are benefits to being treated at the 
requested center which includes a multidisciplinary approach and the advantages of being treated at a cutting-
edge research facility. The requested center has the best outcomes. The Plan denied your request. The Plan says 
you must use in-network providers to receive services/care. This service is available by a provider in your 
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99203) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 11, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations, and the date of consultations in the patients medical record. There 
was no documentation of contact in the patient record.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service October 19, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the lab testing billed for date of 
service October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient evaluation and management (EM) services 
provided on April 11, 2022, billed with code 99239. 
 
You asked the Plan to pay for the EM services provided. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says medical records don't support a hospital discharge day 
management of more than 30 minutes was performed. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes. 
 
We asked our physician 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 EM services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the enrollee is a 68-year-old female who 
was treated at the hospital. A discharge note was provided. However, no documentation was included stating 
duration of time spent on the discharge day management to meet criteria for the 99239 code which requires 
more than 30 minutes duration. Therefore, the provided records do not support the code, 99239. 
 
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 EM services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient evaluation and management (EM) services provided on April 11, 2022, 
billed with code 99239.
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 ventilator. You say that home BIPAP is not appropriate for meeting the 
enrollee's ventilatory requirements. The Plan denied your request. The Plan says the requested 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. 
 
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 ventilator. Our reviewer says that a ventilator is not medically necessary. Our physician reviewer found the provided records in this case document 
a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease and obstructive 
sleep apnea. The reviewer also found that the provided records do not document trial and failure of a bilevel 
positive airway pressure (BiPAP) device with Average volume-assured pressure support (AVAPS) and a back-
up rate. Therefore, the reviewer found that the requested ventilator is not medically reasonable or 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).