Persius/hicric huggingface dataset:
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 enrollee requires a place that is able 
to care for their complex needs. The Plan denied your request. The Plan says the enrollee is receiving the care 
needed in the hospital where they are now and there is no need to transfer to the LTACH at this time. 
 
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 unstable and requires additional acute care services that can 
safely be provided at the current facility until more stable and appropriate for transfer. The enrollee does not 
require services at the LTACH that is 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy. It is the subject of ongoing clinical trials. 
 
   
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the OON cataract surgery . You say that there is no way to know if your 
retina is deteriorating since your cataracts are so bad. You say that you have macular pucker and problems with 
keratitis that should be monitored. You say that it is counterproductive to wait for deterioration before surgery. 
You say that your ability to drive could be compromised if your cataracts continue to worsen and this would 
leave you homebound. You say that past history and present events do not give you confidence that the 
timeframe outlined for surgery will be met.  The Plan denied your request. The Plan says cataract surgery can 
be performed by a network provider in a reasonable period of time. The Plan says that the wait time for surgery 
with the requested OON provider is longer than the wait times quoted by network providers.  
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The case file shows that the Plan verified the wait 
time for surgery with the requested OON provider is longer than the wait time for surgery with an in-network 
provider. We found no exception that would require the Plan to pre-approve these services with an OON 
provider. Therefore, we decided that the Plan does not have to pre-approve cataract surgery to be provided by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (29827, 29826 and 29823) billed 
for date of service January 9, 2023. 
 
You asked the Plan to pay for surgical assistant services. You say that these services were necessary, and the 
enrollee has no say in who provided these services. The Plan denied your request. The Plan says these services 
were performed by an ineligible provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services (29827, 
29826 and 29823) billed for date of service January 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11405 and 99305 billed for date of service 
March 14, 2023. 
 
You asked the Plan to pay for procedure codes 11405 and 99305. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these codes are not 
supported as 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. 
 
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 procedure codes 11405 and 99305. Our reviewer says that 
these codes are not supported in the records provided. Our reviewer found that 8 square centimeters were 
debrided. In this case, 12 units of code 11405 cannot be verified, as this procedure is not supported in the 
procedural report. In addition, the report indicates that the reason for evaluation and management service (99305) is wound care. In this case, this procedure would not be reported separately from the primary 
procedure.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 11405 and 99305 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 11405 and 99305 billed for date of service March 14, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on August 13, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 an Emergency Department visit, for the 
evaluation and management of a patient, requiring medical decision making of high complexity. 
 
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 procedure code 99285. Our reviewer says that the records 
provided do not support the code billed. Our reviewer found the provided records do not show medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. 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 provided on August 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that Ilumya is a medical necessity for you. The Plan denied 
your request. The Plan says Ilumya is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Ilumya. Our reviewer says that 
treatment with Ilumya is not medically reasonable and necessary in this case. Our physician reviewer found 
that you have a diagnosis of psoriasis vulgaris. The FDA has stated that the requested drug is indicated for your 
condition. The record provided does not include the results of an evaluation for tuberculosis exposure. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Ilumya.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical condition and care 
requirements cannot be adequately addressed in a lower level of care. The Plan denied your request. The Plan 
says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Custom Apollo Full Hereditary CGx Panel provided on 
June 14, 2021, and billed with codes 81201, 81408, 81162, 81406, 81404, 81403, 81405, 81292, 81295, 81298, 
81307, 81317, 81321, and 81407. 
 
You asked the Plan to pay for the Custom Apollo Full Hereditary CGx Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the Custom Apollo Full Hereditary CGx 
Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Custom Apollo Full 
Hereditary CGx Panel provided on June 14, 2021, and billed with codes 81201, 81408, 81162, 81406, 81404, 
81403, 81405, 81292, 81295, 81298, 81307, 81317, 81321, and 81407.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 11, 2023, to 
April 9, 2023. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. 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 start of care date is March 11, 2023. The NOA was not received by the Plan until May 25, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from March 11, 2023, to April 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the back pain is due to multifactorial causes and there is retropulsion of the L1 
fracture. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve L1 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding a previous diagnosis of osteoporosis for which the enrollee is being treated. There is no 
indication of a progression of the body height loss, worsening pain, kyphotic deformity, or a severe impact on 
daily activities. Moreover, there is magnetic resonance imaging corroboration of retropulsion and other 
plausible causes of back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on April 1, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 an Emergency Department visit for the 
evaluation and management of a patient, requiring medical decision making of a high complexity. 
 
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 procedure code 99285. Our reviewer says that the records do 
not support the billed service. Our reviewer found the provided records do not reflect medical decision making 
of high complexity.  
We looked at this coder's review, the file, and Medicare rules. 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 provided on April 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve 
ablation is experimental for knee pain.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36471 billed for date of service March 6, 
2023. 
 You asked the Plan to pay for procedure code 36471. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 36471 is bundled into payment for code 36465. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 36471 
is a column II code to column I code 36465. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 36471 billed for date of service March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99418 billed for date of service January 23, 
2023. 
 
You asked the Plan to pay for procedure code 99418. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99418 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99418 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99418 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99418 billed for date of service January 23, 2023.
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 enrollee's needs are complex, and 
they would benefit from services at a LTACH. The Plan denied your request. The Plan says the enrollee's 
records do not indicate that they will need daily physician visits nor specialty nursing care once they complete 
their acute hospital stay. 
 
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 and should only require short-term 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 soon. The enrollee does not require services at the LTACH that is 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 long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 16, 2022, 
to October 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 16, 2022, to 
October 15, 2022.