Persius/hicric huggingface dataset:
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 admission to the LTACH is more 
appropriate than other levels of care, and you would like reconsideration based on the records submitted. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements for admission to the 
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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service November 8, 
20222. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on January 6, 2023. A comparison of the claim lines shows these are duplicates. There is no evidence to 
support that the billed /services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99285 billed for date of service 
November 8, 20222.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the services 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 99223 is: Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.. 
 
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 99223. Our reviewer says that procedure 
code 99223 does not meet criteria for payment. Our reviewer found that the physical examination was not 
comprehensive. 
 
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 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 billed for date of service October 18, 2022.
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 your lungs and body need rehabilitation.  
The Plan denied your request. The Plan says admission to an 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 all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that you require that are not available at the health care setting 
being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrimsRA test billed for date of service November 30, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the test predicts a non-response to tumor 
necrosis factor alpha inhibitor. The Plan denied your request. The Plan says the test is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The test is not FDA approved or have clearance as a companion diagnostic. 
The test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the PrimsRA test billed for 
date of service November 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the code 76942 provided on June 16, 2022.  
 
You asked the Plan to pay for procedure code 76942. You say that there should have been payment for this 
code.  The Plan denied your request. The Plan says no separate payment is made for code 76942. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 76942 is listed as not separately paid in the ASC payment book. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76942 have not been met. Therefore, we decided that the 
Plan does not have to pay for the code 76942 provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00811) provided on January 19, 2023. 
 
You asked the Plan to pay for anesthesia services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of anesthesia services have not been met. Specifically, the services at issue have been billed with POS 
code 22, indicating an outpatient hospital. However, the Plan has documented that the enrollee was admitted as 
an inpatient on the date of service at issue. Reporting an outpatient POS is not appropriate in this case. Therefore, we decided that the Plan does not have to pay for anesthesia services (00811) provided on January 
19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0651, 
E0667). 
 
You asked the Plan to pre-approve an intermittent limb compression device. You say that the requested item is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
pneumatic compression devices have not been met. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. 
 
The file does not show that the enrollee has undergone a trial of conservative therapy. Therefore, we decided 
that the Plan does not have to pre-approve an intermittent limb compression device (E0651, E0667).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
December 5, 2022.  
 You asked the Plan to pay for the ED services. You say that you were told to submit your Medicare number; 
however, you are not certified by Medicare. As such, you feel that this should be paid without that information. 
The Plan denied your request. The Plan says Medicare does not allow payment for freestanding EDs. 
 
The Plan must follow Medicare rules. Medicare rules say that generally freestanding EDs cannot be paid unless 
they are affiliated with a hospital. The COVID waiver allowed these providers to register as temporary 
hospitals in order to receive payment from Medicare.  
 
We looked at the file and Medicare rules. The file indicates that the provider did not register as a temporary 
hospital.  Based on this information, we decided that Medicare rules for coverage of the ED services have not 
been met. Therefore, we decided that the Plan does not have to pay for the emergency department (ED) 
services provided on December 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial for admission to an 
inpatient rehabilitation facility. The Plan denied your request. The Plan says that the request does not meet 
requirements for approval. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery back-up (E1399). 
 
You asked the Plan to pre-approve a battery back-up . You say that  the enrollee warrants a backup battery 
device to be used during electrical power outages. The Plan denied your request. The Plan says the equipment 
does not meet Medicare criteria for approval.  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a battery back-up (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel the IRF services are more aggressive, and 
you want to heal and get back home. The Plan denied your request. The Plan says the requested IRF admission 
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 complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (romosozumab-aqqg) (J3111). 
 You asked the Plan to pre-approve Evenity. You say that you have taken Evista for ten years. You say that you 
stopped taking Fosamax due to medical issues your primary care doctor thought it was causing. You also say 
that despite being on these medications you have broken your wrist three times. The Plan denied your request. 
The Plan says the enrollee has not tried and failed the preferred drug, an injectable bisphosphonate. 
 
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 Evenity. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, an injectable bisphosphonate. The reviewer also found 
that documentation does not indicate that the enrollee has a contraindication to or would have an adverse effect 
from the Plan's preferred drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (romosozumab-aqqg) (J3111).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 30, 2022, to July 
1, 2022, 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 the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 secondary diagnosis code J96.21, described as 
Acute and chronic respiratory failure with hypoxia. 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 documentation does 
not support the billed code. Our physician reviewer found that the enrollee presented with shortness of 
breath. The enrollee was found to have rapid-rate atrial fibrillation, which was corrected. While the enrollee has 
end-stage Chronic obstructive pulmonary disease, there is no evidence that the enrollee had acute respiratory 
failure. As such, the billing of J96.21 is not supported.  
 
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 June 30, 2022, to July 1, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT PNS system.  
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the SPRINT PNS system is 
medically necessary. The Plan denied your request. The Plan says there is insufficient medical literature to 
support the use of the SPRINT PNS system for chronic shoulder pain. Although it is Food and Drug 
Administration (FDA) approved, it is still under review for an indication for use in chronic pain management. 
FDA approval does not equate with Medicare coverage. Until results of clinical research definitively support 
the use of the SPRINT PNS system for chronic shoulder pain, it is not reasonable or necessary with respect to 
Medicare coverage 
 
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 the SPRINT PNS system. Our reviewer says that the requested the SPRINT PNS system is  not considered medically reasonable and necessary in this 
case. Our physician reviewer found that this enrollee was being treated for primary osteoarthritis of the left 
shoulder. The enrollee  presented with left shoulder pain that is aching and moderate to severe. The pain is 
rated 5 at best and 9 at worst. The exam reveals tenderness over the left shoulder subacromial bursa and 
acromioclavicular (AC) joint. There is pain in the range of motion of the shoulder. However, there is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested SPRINT PNS over standard treatment in this clinical setting. No compelling rationale 
is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested SPRINT PNS system, in this case, is not medically reasonable or 
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 SPRINT PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT PNS system.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for  the discharge management services provided on January 11, 2023.  
 
You asked the Plan to pay for  the discharge management services. You say that the services should be paid as 
billed. The Plan denied your request. The Plan says that this cannot be paid because the code is not allowed for 
payment in the emergency room setting.  
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a clear denial rationale that applies to the case at 
issue. The rationale indicates that the place of service (POS) code is inappropriate to report with code 99238, 
and the claim must be denied for this issue. However, the rules cited do not appear to imply this. As of January 
1, 2023, code 99238 is used for both inpatient and outpatient discharge services. While the enrollee may have 
been in outpatient observation, the record indicates that the services were provided in a comprehensive 
psychiatric emergency program. This would support the use of the emergency room (POS) code with the 
outpatient discharge services. Therefore, we decided that the Plan has to pay for  the discharge management 
services provided on January 11, 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.