Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90945 and 99223 rendered on May 31, 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 the services are not supported without the required documentation.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 90945: 
 
Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal 
replacement therapies), with single evaluation by a physician or other qualified health care professional 
 
CPT 99223: 
 
Initial 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, 75 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there are no records from the date 
of service in question. As such, the billing of CPT 99223 and CPT 90945 for 5/31/2023 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 90945 and 99223 rendered on May 31, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met.  
The Plan follows Medicare rules. Medicare rules say that a epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain requirements are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that the services are medically necessary. Our physician reviewer found this is a different side 
than the prior injection. Therefore, the request meets the LCD criteria and is 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 an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection (62323).  
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the guidelines for care in 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 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 has ongoing acute medical issues and still requires acute care services. 
The enrollee continues to receive acute care services and these have not been denied. The enrollee does not 
require services that they are not currently receiving but that would be available at the LTACH facility. The 
elements of the coverage rules are not satisfied and 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the specialist office visit provided on 
February 4, 2023. 
 
You asked the Plan to reduce the deductible for the specialist office visit. You say that you should not have to 
pay any additional costs for this service. 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. Your 
contract with the Plan says that there is a $300 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
 
 You have been asked to pay $152 towards the deductible for the specialist office visit. The item or service you 
asked the Plan to reduce the deductible for falls within the physician/practitioner services, including doctor's 
office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $300 deductible which applies to physician/practitioner services, including doctor's office visits. This 
cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received 
on February 14, 2023. Therefore, we decided that the Plan does not have to reduce the deductible for the 
specialist office visit provided on February 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion. 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says you do not meet the requirements for approval. 
 
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 sacroiliac joint fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the detailed documentation is not evident regarding imaging or radiographic evidence 
supporting a sacroiliitis pathology. The provided examinations did not corroborate multiple findings suggestive 
of sacroiliac joint pathology. There is no clear failure of conservative treatment directed to the sacroiliac joint. 
Multiple other plausible pain generators including at the lumbosacral spine are evident. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one additional day per week at the Day Center. 
 
You asked the Plan to pre-approve additional Day Center services. You say that you are not able to participate 
in the offered outings at the current facility due to your limited funds. You say that you would like an 
additional day at the Day Center to be around people you know and love. You also say that a reduction in days has caused you to be depressed and with increased mental strain. The Plan denied your request. The Plan says 
an extra day per week is not required to fulfil your individualized care plan. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
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 additional Day Center services. Our 
reviewer says that the requested for additional Day Center services is not medically necessary. Our physician 
reviewer found the provided records do not include evidence to support that increased adult daycare services 
are medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional Day Center services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve one additional day per week at the Day Center.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 5 units of code 87481 billed for date of service May 25, 
2023. 
 
You asked the Plan to pay for 5 units of code 87481. The Plan denied your request. The Plan says the billed 
units are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 5 units of code 87481 Our reviewer says that 
5 units of code 87481 are not supported by the records provided. Our physician reviewer found that the 
laboratory report includes test results for Candida glabrata; Candida albicans; Candida krusei; and Candida 
lusitaniae. In this case, 5 units cannot be verified. The additional unit billed is not supported in documentation 
submitted.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 units of code 87481 have not been met. Therefore, we decided that the Plan 
does not have to pay for 5 units of code 87481 billed for date of service May 25, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve the medication. You say that you do not stock Byooviz and the enrollee did 
complete a trial of Avastin. The Plan denied your request. The Plan says that step therapy requirements have 
not been met. 
 
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 the medication. Our reviewer says that 
the criteria for coverage of Eylea have not been met. Our physician reviewer found that the Plan requires a trial 
of Byooviz before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the Plan's required drug would likely be less 
effective or likely have adverse effects for the 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eylea.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the enrollee has bed sores and 
needs to be helped being moved with bed sores. You also say that the power seat would make it easier for the 
enrollee to get out of bed with a Hoyer lift. The Plan denied your request. The Plan says that the enrollee's 
benefit does not cover this equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 power seat elevation system. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is non ambulatory and transfers via Hoyer lift (dependent transfer) 
to a power wheelchair per NCD 280.16. The enrollee meets criteria for the requested wheelchair accessory. 
 
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 power seat elevation system have been met. Therefore, we decided that the 
Plan has to pre-approve a power seat elevation system (E2300).  
 
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 pay for procedure code 76641 billed for date of service August 3, 
2023.  
 You asked the Plan to pay for procedure code 76641. You say that both units of 76641 should be paid as billed 
because they were appropriately coded using modifiers -LT and -RT. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the -LT modifier and one line 
item of this code with the -RT modifier instead of billing one line item with the bilateral modifier as is 
required. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed 
for date of service August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. You asked the Plan to pre-approve a facet joint injection. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the enrollee has received a previous procedure in the 
same location of the requested injection. 
 
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 facet joint injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the LCD states that diagnostic injections or medial branch blocks at the same level as 
previously successful radiofrequency ablations (RFA) will be denied as not reasonable or necessary. It has been 
confirmed that the targeted areas are the same side and levels as the previously performed RFA procedure 
within the past three months and there is no documentation that the source of recurrent lumbar pain is in 
question. 
 
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 facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facet joint injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing services provided from 
August 1, 2023, to August 28, 2023. 
 
You asked the Plan to waive the copayment for the skilled nursing services. You say that you do not feel the 
enrollee should be liable for the services provided. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $0 copayment per day for days 1-20. The enrollee must pay a $196 copayment per day for days 21-
100 for in-network skilled nursing facility care.  
 The records show the enrollee has not been asked to pay for the skilled nursing services provided from July 21, 
2023, to August 9, 2023. The enrollee has been asked to pay $3,528, which is a $196 copayment per day for the 
remaining 18 days of the skilled nursing services provided from August 10, 2023, to August 27, 2023. The 
enrollee was not charged for the day they were discharged. These services fall within the skilled nursing 
facility care benefit category. This means that the enrollee has been asked to pay the correct amount based on 
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled 
nursing services provided from August 1, 2023, to August 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor.  
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not insulin-treated and does not have a history or problematic 
hypoglycemia. 
 
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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a pacemaker (33208). 
 
You asked the Plan to pre-approve insertion of a pacemaker. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that implanted permanent single chamber or dual chamber 
cardiac pacemakers are 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 insertion of a pacemaker. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is insufficient 
documentation to support the medical necessity for insertion of a pacemaker in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a pacemaker have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of a pacemaker (33208).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BOTOX. 
 
You asked the Plan to pre-approve BOTOX. You say that the enrollee needs for treatment. The Plan denied 
your request. The Plan says the enrollee's medical condition does not meet the criteria. 
 
 
 The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. The local coverage article enumerates additional conditions and limitations of coverage for the 
requested service. 
 
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 BOTOX. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee's condition is not one for which 
coverage is available under the rules. 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 BOTOX have not been met. Therefore, we decided that the Plan does not have 
to pre-approve BOTOX.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 T12 kyphoplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no trial and failure of fracture bracing. More conservative measures are 
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 T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22513).