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

 
We decided that the Plan does not have to pay for code 69209 provided on December 30, 2022. 
 
You asked the Plan to pay for 69209. You say that you have tried several combinations of diagnosis codes that 
would be appropriate. The Plan denied your request. The Plan says there is an Excludes1 note between 
diagnosis codes H91.93 and H61.23 so these codes should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of H91.93 and H61.23. Diagnosis code H61.23 is an 
Excludes1 code under code H91.93, so these two diagnoses cannot be billed together. Based on this 
information, we decided that Medicare rules for coverage of 69209 have not been met. Therefore, we decided 
that the Plan does not have to pay for code 69209 provided on December 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered 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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding an acute or subacute fracture as the enrollee's pain is noted to have started on May 11, 2023. 
There is no indication of a progression of the body height loss, greater than 25% vertebral body height loss, or 
kyphotic deformity. Moreover, there is magnetic resonance imaging corroboration of retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimzia. 
 You asked the Plan to pre-approve Cimzia. You say that the enrollee has tried and failed infliximab and 
methotrexate. You say that the enrollee's pain has not improved with Simponi Aria. You also say that the 
copayments for Humira, Xeljanz and Rinvoq are too high for the enrollee. The Plan denied your request. The 
Plan says the enrollee has not tried and failed at least two of the preferred drugs, adalimumab, Rinvoq, Skyrizi, 
Actemra, Cosentyx, Otezla, Xeljanz, Xeljanz XR, Orencia or Enbrel. 
 
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 Cimzia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of two of 
adalimumab, Rinvoq, Skyrizi, Actemra, Cosentyx, Otezla, Xeljanz, Xeljanz XR, Orencia or Enbrel. The 
reveiwer found that the enrollee has not tried and failed two of the preferred drugs. The reviewer also found 
that there is no documentation provided indicating that the plan's required drugs 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 Cimzia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Cimzia.
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 these services are medically necessary. The Plan 
denied your request. The Plan says the services you need 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 you do not require rehabilitation physician supervision and an intensive rehabilitation 
program. Care can be provided in another 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 billed for January 6, 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 the claim was billed with the incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that the claim was incorrectly billed with POS code 
12 for the home setting. Therefore, we decided that the Plan does not have to pay for procedure code 99308 
billed for January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing coded with Current Procedural 
Terminology (CPT) codes 81403, 81292, 81295, 81297, 81300, 81298, 81319, 81294, 81317. 
 
You asked the Plan to pre-approve the genetic testing. You say that based on an extensive family history of 
cancer, you are requesting reconsideration of this denial. The Plan denied your request. The Plan says the 
enrollee does not have the diagnosis of cancer, therefore, does not meet the LCD criteria and this test would be 
for the purpose of screening. 
 
The Plan must follow Medicare rules. The rules explicitly say that screening tests, with the exception of the 
few tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and Medicare rules. This genetic testing is being requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the genetic testing coded with Current Procedural Terminology (CPT) codes 81403, 
81292, 81295, 81297, 81300, 81298, 81319, 81294, 81317.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 19, 2022, to 
August 17, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. 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 July 19, 2022, to August 
17, 2022.
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 cannot stand, let alone walk, bathe myself 
because the shower at home has a step over. You have fallen several times in the last few months and unstable 
from brain bleeds.  The Plan denied your request. The Plan says you are medically stable and has no skilled 
nursing needs. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily 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 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: 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 oversight to check labs, including blood 
transfusions as needed, manage cardiac status, manage pain, ensure adequate nutritional status, update plan of 
care as needed, coordinate overall rehab program, consult surgeon as needed, and educate patient/family as 
needed. The Plan denied your request. The Plan says the enrollee does not meet the requirements. Services 
needed may be provided safely in a lower level of care. 
 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. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction (78816) 
 
You asked the Plan to pre-approve a Positron emission tomography. The Plan denied your request. The Plan 
says the medical records do not indicate that the enrollee has a cancer that is biopsy-proven or strongly 
suspected, and there is no documentation of the presence or size of a pulmonary nodule. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 Positron emission tomography. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the medical records do 
not indicate that the enrollee has a cancer that is biopsy-proven or strongly suspected, and there is no 
documentation of the presence or size of a pulmonary nodule.  
 
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 Positron emission tomography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) for attenuation correction (78816)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (80307) provided on January 10, 2023. 
 
You asked the Plan to pay for the laboratory service . You say that the claim should be paid. The Plan denied 
your request. The Plan says the proper certificate type was not effective for the date of service billed for the 
CLIA ID billed.  
The Plan must follow Medicare rules. 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. The CLIA ID billed on 
this claim was not effective with the proper certification type for the billed procedure code 80307 and date of 
service, January 10, 2023. 
 Therefore, we decided that the Plan does not have to pay for the laboratory service (80307) provided on 
January 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 you need multiple therapies that are offered in an 
acute facility. The Plan denied your request. The Plan says you do not meet the requirements. Services needed 
may be provided safely in a lower level of care.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA), nerves innervating 
the sacroiliac joint (SIJ) (64625). 
 
You asked the Plan to pre-approve the RFA. You say that outpatient surgery is needed. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the RFA have not been met. SIJ Denervation (also called 
Radiofrequency Ablation or RFA) is not considered reasonable and necessary. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation (RFA), nerves innervating the sacroiliac joint 
(SIJ) (64625).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81552 billed for date of service February 14, 
2023. 
 You asked the Plan to pay for procedure code 81552. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81552 is bundled into payment for code 81445. 
 
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 81552 
is a column II code to column I code 81445. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 81552 billed for date of service February 14, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open abductor exploratory surgery with possible 
gluteus repair. 
 
You asked the Plan to pre-approve the exploratory surgery. You say that the enrollee has failed conservative 
treatment for symptomatic non-arthritic condition of the hip. You also say that the enrollee's persistent pain is 
causing significant disability. The Plan denied your request. The Plan says this procedure is considered 
experimental and/or unproven. 
 
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 the exploratory surgery. Our reviewer 
says that the requested exploratory surgery is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to corroborate the requested surgery have positive outcomes in this clinical setting. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested open abductor exploratory surgery with possible gluteus repair 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 the exploratory surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an open abductor exploratory surgery with possible gluteus repair.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 6 office visits with an out-of-network provider. 
 
You asked the Plan to pre-approve the outpatient services. You say that the enrollee is an established patient 
since 2020. You say that these visits are necessary to check the fit of the existing prostheses and to adjust 
anything as needed. You also say that there are no other maxillofacial prosthodontic providers in the state. The 
Plan denied your request. The Plan says that there are network providers available. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees 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 outpatient services. Our reviewer 
says that the request for 6 out-of-network office visits with a maxillofacial prosthodontist is medically 
necessary. Our physician reviewer found the Plan has not shown there are in-network maxillofacial 
prosthodontists available to provide the requested services. The reviewer found that it would be in the enrollee's 
best interest to follow up with the provider who placed the prosthesis. The reviewer also found that the Plan 
recommended providers are oral surgeons and do not have the training for facial prostheses. Therefore, the 
reviewer found that the 6 out-of-network office visits are 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 the outpatient services have been met. Therefore, we decided that the Plan has 
to pre-approve 6 office visits with an out-of-network provider.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on November 6, 2021, to 
December 2, 2021. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says that the required documentation has not been 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital care provided 
have been met. Specifically, an itemized bill has not been provided for review. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital care provided on November 6, 2021, to December 2, 2021.