Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at the psychiatric inpatient 
hospitalization level of care. 
 
You asked the Plan to pre-approve a continued stay at the psychiatric inpatient hospitalization level of care. 
The Plan denied your request. The Plan says this request does not meet Medicare guidelines because the 
records do not show that the enrollee continues to be a significant risk to themself or anyone else, or needs 24-
hour care for active inpatient psychiatric treatment beyond February 13, 2023. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 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 continued stay at the psychiatric 
inpatient hospitalization level of care. Our reviewer says that the enrollee does not meet the Medicare criteria 
for continued inpatient psychiatric care. Our physician reviewer found it is not expected this enrollee will 
improve in a reasonable period of time beyond the dates in question as the enrollee was not showing any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors. It did not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower 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 a continued stay at the psychiatric inpatient hospitalization level of care have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continued stay at the 
psychiatric inpatient hospitalization level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided August 3, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0482) rendered on May 5, 2022. 
 
You asked the Plan to pay for the services. You say that it is expected for the patient to test positive for an 
opioid due to medication being prescribed to them long-term. The Plan denied your request. The Plan says the 
services provided were processed correctly. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that the records were not sufficient to support that this testing was 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (G0482) rendered on May 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc/Synvisc-One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Synvisc/Synvisc-One is 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records document you had had no 
change in pain with the prior Synvisc injection. There is no record that the injection decreased the amount of 
non-steroidal anti-inflammatory drugs (NSAIDs) medications needed for pain. After the injection, you reported 
new symptoms of "locking and catching." There is no significant pain improvement from the first injection; 
therefore, a repeat injection is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc/Synvisc-One.
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 care the enrollee needs is best 
delivered at an LTACH facility. You also say that the enrollee meets the criteria for an LTACH admission. The 
Plan denied your request. The Plan says the requested service 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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. Our reviewer found that 
the enrollee does not require services at the LTACH that are not available at the acute care hospital where they 
are currently receiving care. 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. Our physician reviewer also found that 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483, 80307) provided on June 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483, 80307) provided on June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve socket replacement (codes L5701, L5950, L5650, 
L5631, L5624, L5649, L5651, L5671, L5673, L5920, L5705, L8430, L8460, and L8480) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a socket replacement. The Plan denied your request. The Plan says 
medically necessary services are available within the enrollee's network, and there are no extenuating 
circumstances making it medically necessary to obtain the service OON. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
socket replacement (codes L5701, L5950, L5650, L5631, L5624, L5649, L5651, L5671, L5673, L5920, 
L5705, L8430, L8460, and L8480) to be provided by an out-of-network (OON) provider.
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 the enrollee will need the multidisciplinary team 
approach to monitor labs and need for supplement, management of pneumonia, and medical changes as needed, 
medical management. The Plan denied your request. The Plan says the IRF services requested do not meet the 
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 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. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical 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. Our physician reviewer also 
found that there is not a reasonable expectation that this patient 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory PCR (polymerase chain reaction) panel 
(87541, 87798) provided on February 2, 2022. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necessary and 
appropriate. The Plan denied your request. The Plan says that this respiratory panel included more than five 
viral pathogens; therefore, these services are not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory PCR panel have not been met. Specifically, this panel included 6 or more 
pathogens. Therefore, we decided that the Plan does not have to pay for the respiratory PCR (polymerase chain 
reaction) panel (87541, 87798) provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service July 5, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service July 5, 2022, billed with 
code 99153.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a quantitative calcium scoring (75571). 
 
You asked the Plan to pre-approve a quantitative calcium scoring. The Plan denied your request. The Plan says 
this is not a covered service. 
 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. 
 
The test at issue in this appeal, a quantitative calcium scoring, is being requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve a quantitative calcium scoring (75571).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 30, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that this claim should be paid. The Plan denied 
your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4220 billed for date of service August 18, 
2021. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says no separate payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that procedure code A4220 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4220 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A4220 billed for date of service August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, multiaxial ankle 
with swing phase active dorsiflexion feature (L5968) and an all-lower extremity prosthesis, flex-walk system or 
equal (L5981). 
 
You asked the Plan to pre-approve lower limb prosthetics. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
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 lower limb prosthetics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee uses a walker. The documentation does not support that the enrollee is a 
K3 ambulator. An addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5968) and an all-lower extremity prosthesis, flex-walk system or equal (L5981) exceeds the enrollee's 
needs and is not medically necessary per Local Coverage Article A52496 and per Social Security Act, Section 
1862 (a)1(A) and the 42 CFR 411.15(k).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an addition to lower limb prosthesis, multiaxial ankle with swing phase active 
dorsiflexion feature (L5968) and an all-lower extremity prosthesis, flex-walk system or equal (L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6446 and A4450 billed for date of service 
March 9, 2022. 
 
You asked the Plan to pay for procedure codes A6446 and A4450. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the billed codes are not covered. 
 
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 codes A6446 and A4450 have a Status Indicator of X on the Physician Fee Schedule. 
This means that procedure codes A6446 and A4450 are statutorily excluded from Medicare payment. Based on 
this information, we decided that Medicare rules for coverage of procedure codes A6446 and A4450 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A6446 and A4450 
billed for date of service March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 99212. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99212 is bundled into 
payment for code 31575. 
 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 99212 
is a column II code to column I code 31575. 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 99212 billed for date of service July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277) and physician or other qualified health care professional attendance and 
supervision of hyperbaric oxygen therapy, per session (99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that you cannot qualify for acute 
therapy, and you need this intervention for treatment of both your feet and toes so that you do not lose them. 
Having your foot and toes amputated because failure of the Plan to cover this treatment, would irrevocably 
affect your health, wellbeing, and quality of life. The Plan denied your request. The Plan says the request for 
HBOT is not medically necessary. Your records do not show a diagnosis of acute peripheral ischemic or gas 
gangrene. The medical records support that you have chronic peripheral vascular disease for which this service 
is not covered. 
 
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 hyperbaric oxygen therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided records in this case indicate your condition is chronic. Records 
document an acute arterial occlusion on February 16, 2023, that was treated inpatient with placement of a lytic 
catheter. Your condition improved with this treatment, and you were discharged from the hospital. An 
outpatient visits note of March 6, 2023, documents "chronic occlusion of the ATA." You have "stable dry 
gangrene" and are not diabetic. As stated in the National Coverage Determination (NCD): Hyperbaric Oxygen 
Therapy - 20.29: "No program payment may be made for HBO in the treatment of the following conditions, 
chronic peripheral vascular insufficiency." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute interval 
(G0277) and physician or other qualified health care professional attendance and supervision of hyperbaric 
oxygen therapy, per session (99183).