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

 
We decided that the Plan does not have to pay for unclassified drug injections (J3490) provided on April 24, 
2023. 
 
You asked the Plan to pay for unclassified drug injections. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the plan does not cover naturopathic services under any condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for unclassified drug injections (J3490) provided on April 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says when the enrollee is ready to leave the hospital, they can discharge or 
transfer to another level of care such as skilled nursing facility, this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is unlikely to need more than 25 days in LTACH and if their small bowel 
obstruction does not resolve soon, they may require surgery. As such, the enrollee is best served in their current 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic services described by code 93971 performed 
on date of service January 29, 2023. 
 
You asked the Plan to pay for 93971. You say that 93971 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 93971 is denied because it was billed without the 
required modifier -26. 
 
The Plan must follow Medicare rules. Medicare rules say that if a diagnostic test which has a separate technical 
component (TC) and professional component (PC) is provided under arrangement to a hospital, the physician 
who reads the test can bill and be paid for the professional component.  
We looked at the file and Medicare rules. We confirmed that 93971 is a diagnostic service which has separate 
TC and PC. The claim was billed with place of service (POS) 23, indicating services were rendered in a portion 
of a hospital where emergency diagnosis and treatment of illness or injury is provided. As such, POS 23 
indicates services were provided in the facility setting, under arrangement to a hospital. According to Medicare 
rules, the provider performing the professional interpretation of the diagnostic service provided under 
arrangement to a hospital can bill and be paid for the PC of the service. The PC of a diagnostic service should 
be documented on the claim form with modifier -26. We have confirmed that 93971 was billed without the 
required modifier -26. 
 
Based on this information, we decided that Medicare rules for coverage of 93971 have not been met. Therefore, 
we decided that the Plan does not have to pay for the diagnostic services described by code 93971 performed 
on date of service January 29, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve bortezomib (Velcade) (J9041). 
 
You asked the Plan to pre-approve Velcade. You say that given the patient's excellent response to Velcade in 
the past, it is the best option for treatment in this case. The Plan denied your request. The Plan says that this 
request does not meet medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Velcade. Our reviewer found that the 
enrollee has scleroderma and monoclonal gammopathy of unknown significant (MGUS). The enrollee received 
prior intravenous immune globulin (IVIG) in 2017, as the scleroderma is felt to be related to the MGUS. When 
the scleroderma became worse, the enrollee was treated with velcade and dexamethasone with good response 
and discontinued. The plan is to use Velcade and Dexamethasone again. Our physician reviewer found that 
although the requested use of Velcade is not FDA approved for the enrollee's diagnosis, the use of this drug is 
supported by the major drug compendia and clinical research that appears in a Medicare-approved medical 
journal. The use of this drug for the enrollees' condition is not listed as not indicated, not supported, or not 
recommended in any of the compendia. Our reviewer also found that the documentation supports that the 
requested drug is safe, effective, and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Velcade have been met. Therefore, we decided that the Plan has to pre-approve 
bortezomib (Velcade) (J9041).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance including arthrography when performed (27096). 
 You asked the Plan to pre-approve injection procedure for sacroiliac joint. You say that this is medically 
necessary. The Plan denied your request. The Plan says records do not show at least three positive findings 
with provocative maneuvers on physical examination. The request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections 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 injection procedure for sacroiliac joint. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the physical 
examination does not support the diagnosis of SI joint pain and dysfunction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection procedure for sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve injection procedure for sacroiliac joint, anesthetic/steroid, 
with image guidance including arthrography when performed (27096).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) system. You asked the Plan to pre-approve a Freestyle Libre 14-day CGM system. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 14-day CGM system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor (CGM) system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the requirements for 
admission to the LTACH. You also say the enrollee is not stable enough to go home and requires more care 
than what is expected at a skilled nursing facility (SNF). The Plan denied your request. The Plan says 
admission to the LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the provided records do not explain what care services will be provided in the 
LTACH that are not available in the present hospital setting. The acute hospital can provide for all the enrollee's present inpatient care needs and the Plan has stated that continued care in the short-term acute 
hospital will be covered as is medically indicated. The enrollee is presently receiving appropriate services in 
the acute care setting. Records do not support the need to transfer from one acute hospital to another. 
Continued care in the short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower 
level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 
facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says that the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH 
that are not available at the health care setting being offered by the Plan.  Given there are offered alternatives, LTACH services are not medically 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on February 21, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the enrollee was seen in the emergency department (ED) for feet pain. An appropriate history and physical 
examination were documented. The medical decision making was not of high complexity. As such, the billing 
of CPT 99285 is 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 an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on February 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
August 13, 2023, to August 15, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you received poor care 
from the facility. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for inpatient hospital care. 
 
You have been asked to pay a $300 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $300 for the inpatient hospital stay ($350 copayment 
x 1 day = $300). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on August 13, 2023, to 
August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95861, 95868, and 95865 billed for date of 
service June 29, 2022.  
 
You asked the Plan to pay for procedure codes 95861, 95868, and 95865. You say that 95861, 95868, and 
95865 should be paid as billed because they were coded accurately and billed correctly. The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed.  
 
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 codes 95861, 95868, and 95865 is 1. The MAI value for these codes is 3. You 
billed 2 units of each code, exceeding the MUE for each. We have confirmed there are no medical records 
provided in the case file for review. As such, you did not provide all the required evidence showing that the 
excess units were actually provided, were correctly coded, and were medically necessary. Of note, the case file 
does contain evidence that the Plan requested these records. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95861, 95868, and 95865 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 95861, 95868, and 95865 billed for date of 
service June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the LTACH 
admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment but still unstable for 
transfer and requires additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care. The enrollee does not require LTACH services that 
are not already available at the current facility. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH is not medically 
necessary as the enrollee is still unstable for transfer and as it would not be clinically advantageous. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the long-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. The 
documentation does not support that an additional 25 days of hospitalization are reasonably expected for the 
enrollee in this case. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99284) provided 
on May 19, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99284). You say that procedure code 
99284 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 a medically appropriate history and/or examination and moderate 
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 an emergency department visit (procedure 99284). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the enrollee was evaluated in the emergency department (ED) for a bloody nose. A limited history and 
appropriate physical examination were documented. The medical decision making was not of moderate 
complexity. As such, the billing of CPT 99284 is 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 an emergency department visit (procedure 99284) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99284) 
provided on May 19, 2023.