Persius/hicric huggingface dataset:
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 it is not safe for the enrollee to be at home. The Plan 
denied your request. The Plan says the enrollee does not require complex daily nursing care and daily skilled 
rehabilitation therapy. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis (L3670), provided on February 20, 
2023. 
 
You asked the Plan to pay for the shoulder orthosis. You say that this item should be covered. The Plan denied 
your request. The Plan says this is a duplicate item. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that J. Kalsi had a shoulder orthosis at the time the shoulder orthosis was received. a shoulder 
orthosis serves the same purpose as  the shoulder orthosis. Therefore, we decided that the Plan does not have to 
pay for the shoulder orthosis (L3670), provided on February 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service July 22, 
2022.   
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. 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 code 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93284 billed for date of service May 9, 2023.  
 You asked the Plan to pay for procedure code 93284. You say that the claim is billed correctly and should be 
paid. 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 code 93284 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 93284 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93284 billed for date of service May 9, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested injections are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the step therapy requirements for Prolia 
(denosumab).  
 
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 Prolia. Our reviewer says that the 
requested drug does not meet the criteria necessary for approval. Our physician reviewer found the Plan 
requires a trial of a bisphosphonate drug before they will approve the requested drug. The provided records do 
not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from, the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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's attending physicians agree, 
the enrollee is stable and appropriate for transfer to an LTACH. The Plan denied your request. The Plan says 
the enrollee does not meet all the requirements for an 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 the current treatment. The enrollee should 
only require short-term additional acute care hospital services that can safely be provided at the current facility 
until she is more stable and appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the stance control (L5845). 
 
You asked the Plan to pre-approve the stance control. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that this item is already included in the base knee. 
 
The Plan follows Medicare rules. Medicare rules say that L5925, L5930, L5845, L5848, L5850, L5856, L5857, 
L5858, L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin 
system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5616, 
L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840).  
 
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 stance control. Our reviewer says 
that the item is medically necessary. Our physician reviewer found the L5845 code describes an adjustable 
stance flexion feature, which is separate and distinct from both the swing phase control and the mechanical 
stance phase lock anticipated in L5814 by itself.  Moreover, L5845 is expressly allowed as an addition code to 
L5814 per Policy Article A52496. 
 
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 stance control have been met. Therefore, we decided that the Plan has to 
pre-approve the stance control (L5845).  
 
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 services provided on February 5, 2023, to 
February 9, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that A41.9 is 
supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says A41.9 is not supported in the documentation. 
 
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 principal diagnosis A41.9, defined as sepsis, 
unspecified organism. 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 principal diagnosis A41.9 is not supported in the 
documentation. Our physician reviewer found the enrollee with recently diagnosed influenza presented to the 
hospital with progressive worsening of symptoms and poor oral intake. Workup revealed pneumonia, 
dehydration, and acute kidney injury. They were started on fluids, Tamiflu, and antibiotics. The enrollee had 
leukocytosis, creatinine level of 0.91 after fluids, 91% oxygen saturation on room air, Glasgow Coma Score 
(GCS) was 15, platelets were normal, bilirubin was normal, and blood pressure was normal/stable. 
Documentation did not sufficiently show oliguria or an abnormal blood gas. Therefore, there was insufficient 
evidence of a dysregulated response to systemic infection leading to organ failure. Sepsis 3 criteria was not 
met, and overall documentation did not support the code, A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 5, 2023, to February 9, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service April 4, 2023, and 
April 5, 2023. 
 
You asked the Plan to pay for code 99233. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says code 99233 is not supported by the medical record. The 
records don't support a high level of medical decision making or total time required of the code 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 code 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded.  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found this case pertains to a 79-year-old female who was 
admitted to the hospital for Methicillin-resistant Staphylococcus aureus (MSSA) bacteremia. The 
documentation provided does not support a high-level of decision-making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service April 4, 2023, and April 5, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 6 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that the services are medically necessary. 
The Plan denied your request. The Plan says there is not clinical information to show why the PT services are 
needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested physical therapy is generally accepted as a 
specific and effective therapy for weakness and difficulty with coordination in the setting of Parkinsons 
Disease. The enrollee has had 13 sessions of physical therapy and some improvement is noted. However, there 
is insufficient documentation regarding objective improvement in strength, range of motion and function. 6 
sessions have been approved to transition to a home exercise program. Therefore, the 6 visits of additional 
physical therapy 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 the additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 6 physical therapy (PT) visits.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J1569 billed for date of service March 2, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records show medical necessity. The 
Plan denied your request. The Plan says that the claim was not billed with a covered diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan states that 14 diagnosis codes were billed. The Plan did not 
provide the claim at issue. The Local Coverage Article, A57554, the Plan used in their decision to deny 
services is not binding in this case. The guidelines do not have jurisdiction where the services were provided. 
The Plan offered no other ruling as part of their rationale. The Plan has not made reasonable and diligent efforts 
to gather and forward to us information regarding their decision to deny your request. Therefore, we decided 
that the Plan has to pay for procedure code J1569 billed for date of service March 2, 2023.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records provided does not establish 
that the enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal dementia or that 
the examination is being requested in the context of a clinical trial. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
oncologist. 
 
You asked the Plan to pre-approve a continuation of care with an OON oncologist. You say that you need to 
continue care with the oncologist that has been taking care of you since you were diagnosed with cancer. You 
say that this doctor is familiar with your case.  The Plan denied your request. The Plan says it is not medically 
reasonable and necessary to see an OON oncologist. The Plan says that the services needed can be provided by 
a network oncologist.  
 
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. Medicare rules also say that for Medicare to consider coverage and 
payment for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a continuation of care with an OON 
oncologist. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found 
the enrollee has a history of lymphoma. Otherwise, there is minimal medical documentation provided which 
lays out a cancer diagnosis, prognosis, current state, or treatment plan. There is no evidence that the enrollee 
requires care from an OON provider.  
 
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 continuation of care with an OON oncologist have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
oncologist.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high activity knee control frame (L5930). 
 
You asked the Plan to pre-approve a high activity knee control frame. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 high activity knee control frame. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee does not need 
this item. 
 
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 high activity knee control frame have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a high activity knee control frame (L5930).