Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 8, 2023, to April 
3, 2023. 
 You asked the Plan to pay for the home health services. You say that the bill type is correct and there is no lack 
of information, so the claim should be paid. The Plan denied your request. The Plan says the NOA was not 
received. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from March 8, 
2023, to April 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335 rendered on February 23, 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 procedure code 27335 is considered inclusive to CPT 27447. 
 
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 27335 is "Arthrotomy, with synovectomy, knee; anterior 
AND posterior including popliteal area."  
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 records do not support CPT 
27335: arthrotomy with synovectomy, knee, anterior AND posterior including popliteal area, as a separate and 
distinct procedure from CPT 27447: arthroplasty, knee, condyle and plateau; medial AND lateral compartments 
with or without patella resurfacing (total knee arthroplasty). The enrollee was being treated for pain, synovitis 
and tenosynovitis of the left lower leg. She underwent a left total knee arthroplasty with major synovectomy of 
the knee on 2/23/23. The procedure details cite a full three-compartment synovectomy was performed 
including the suprapatellar pouch, the peripatellar region, both gutters, and the posterior compartment. This 
was after the tibial and femur cuts were made and the trials were placed. However (and despite the 
synovectomy being done post bony cuts), the records evidence that the synovectomies were done to optimize 
implant fit and tracking 
 
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 procedure code 27335 rendered on February 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee is diagnosed with ischemic 
cardiomyopathy and Entresto is medically necessary for them to have. The Plan denied your request. The Plan 
says that self-administered drugs do not fall under Medicare Part B coverage. 
 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 Entresto.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiology office visit provided on April 4, 2023. 
 
You asked the Plan to pay for the cardiology office visit. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this out-of-network office visit is not medically necessary. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a cardiology office visit provided on April 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission provided from November 13, 2022, to 
November 21, 2022. 
 
You asked the Plan to pay for the inpatient admission. You say that the inpatient admission was medically 
necessary and incorrectly denied. The Plan denied your request. The Plan says the enrollee's emergency 
medical condition stabilized by November 15, 2022, and subsequent care was post-stabilization care, not 
approved in compliance with the Plan's authorization procedures. The Plan says that the Plan has paid for all 
emergent care up to the point of stability. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient admission. Our reviewer says 
that post-stabilization care was not medically necessary in this case. Our physician reviewer found that as of 
November 15, 2022, the enrollee was stable and appropriate for ambulance transport with monitoring because 
her altered mental status had improved and she was at her baseline. The enrollee did not need intensive care 
unit (ICU) level of care and the enrollee transitioned from bilevel positive airway pressure (BiPAP) to 
3L/Nasal Cannula with no respiratory deterioration. The enrollees troponins were trending down, and she was 
eating. Post -stabilization care services at the non-Plan facility as of November 15, 2022 were not medically 
necessary or reasonable. The review has determined that the treating physician did not document (in the 
physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.  
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for an inpatient admission provided from November 13, 2022, to November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 3, 2023. 
 
You asked the Plan to pay for the medical services. You say that this claim should be allowed separately. The 
Plan denied your request. The Plan says you billed this claim with an incorrect Place of Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87186 billed for December 12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87186 billed for December 12, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services reported with DRG 640 rendered from 
December 12, 2022, to December 20, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says that the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 640. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were supported by the medical records. Our physician reviewer found that 
the documentation does clearly state that the enrollee was diagnosed with metabolic encephalopathy with 
altered mental status and dehydration, thus code G93.41 is supported. The records more support DRG 640 
rather than DRG 641. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services reported with DRG 640 rendered from December 12, 2022, to December 20, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on October 16, 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 recommendation is to downcode to CPT 99282. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for 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 documentation does not 
support the level of care for CPT 99284. The records do not support a detailed history, detailed examination, or 
medical decision making of moderate complexity. The records do not support that the presenting problems 
were of high severity. 
 
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 emergency room services (procedure code 99284) rendered on October 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 12, 2023, to 
February 10, 2023. 
 You asked the Plan to pay for the home health services. You say that you submitted the required NOA on April 
17, 2023.  You said that you first billed Original Medicare because that is the insurance that you thought the 
patient had. You said that other plans do not require submission of a NOA. The Plan denied your request. The 
Plan says the NOA was not received. As such, this final claim was correctly denied. The Plan says that 
although your appeal stated that the NOA was submitted, none has been received. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from January 12, 
2023, to February 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement. 
 
You asked the Plan to pre-approve a total knee replacement. You say that the member has had multiple 
injections, and he cannot tolerate therapy because of his bone-on bone arthritis. The Plan denied your request. 
The Plan says there is a lack of documentation supervised physical therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a total knee replacement. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the diagnostic imaging studies did not support severe left knee osteoarthritis. There 
are clearly documented recurrent effusions/hemarthroses of the left knee associated with increased left knee 
pain. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical 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 a total knee replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee replacement.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that the enrollee would 
benefit from this procedure. The Plan denied your request. The Plan says medical studies have not proven this 
service is helpful for the treatment of the enrollee's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Vertiflex device is experimental, and more research is 
needed. 
 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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of teeth and bone grafts. 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are not for a tooth 
removal they are for bone surgery, and you need it taken care of. The Plan denied your request. The Plan says 
the requested dental services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the dental services are not medically necessary. Our physician reviewer found that tooth #22 area had a 
history of prior excision of a keratocyst in 2020 that has recurred. The treatment plan calls for the removal of 
the recurrent cyst along with removal of teeth #5, #6, #7, #8, #10, #13, #14, #15, #23, #24, #25, #26, #27, and 
#28 along with alveoloplasty. The cyst was of dental origin, and under Medicare the treatment of the cyst 
would not be a covered service. Tooth removal is specifically excluded under Medicare, though a supplement 
under the Plan would allow for simple extractions where medically necessary. As there are no supplied x-
rays there is no manner to assess medical necessity for removal of the teeth requested. There has been no clear 
showing of need for the requested extractions, or x-rays to support the request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the removal of teeth and bone grafts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on January 30, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for telehealth services. You say that the enrollee didn't know that the rendering 
provider was not participating within the Plan's network. The Plan denied your request. The Plan says this 
provider is not a network provider. 
 
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 telehealth services provided on January 30, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 5, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are asking for reconsideration to have the denied 
claim reprocessed for payment. The Plan denied your request. The Plan says the provider is not a network 
provider. They have also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 an office visit provided on May 5, 2023, by an 
out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says that the enrollee must try and fail Orthovisc, Synvisc, or Synvisc-One 
first. 
 
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 looked the file and Medicare rules. Medicare step therapy criteria can only be applied to new prescriptions 
or administrations of Part B drugs, using a 365-day lookback period. This limitation must be applied to all 
enrollees and means step therapy for a Part B drug may be used only for an enrollee who is not receiving the 
medication currently or has not previously received the medication within the lookback period. The file shows 
that the enrollee has received Euflexxa within the last 365 days. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have been met. Therefore, we decided that the Plan has to pre-approve 
Euflexxa.  
 
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.