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

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99221 provided on 
June 7, 2022. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says this service is not separately payable. 
 
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 99221 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and Medical decision making that is straightforward or of low 
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 low severity. Typically, 30 minutes are spent 
at the bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99221 is not supported in the medical record. Specifically, this service was provided on 
the same date of service as the minor surgery procedure identified as code 13121 (Repair, complex, scalp, 
arms, and/or legs; 2.6 cm to 7.5 cm). This means that this code is included in the global surgery period of code 
13121 and is not separately payable. Based on this information, we decided that Medicare rules for coverage of 
the initial hospital care services have not been met. Therefore, we decided that the Plan does not have to pay 
for the initial hospital care services coded 99221 provided on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 2 Reader. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation does not show that the enrollee is using insulin. 
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre 2 Reader.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 97110. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the available 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 97110 is: Therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
 
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 97110. Our reviewer says that procedure 
code 97110 does not meet criteria for payment. Our reviewer found that procedure code 97110 is a timed 
procedure code, "each 15 minutes." The available documentation describes 5 minutes. Therefore, this 
procedure cannot be verified. 
 
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 97110 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 97110 billed for date of service May 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 29, 2022, to 
May 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 April 29, 2022, to May 
28, 2022.
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 admission to a Long-Term 
Acute Care Hospital is needed. The Plan denied your request. The Plan says the records do not show that the 
enrollee needs continued treatments and care that can only be given in a hospital setting. When ready to leave 
the hospital, the enrollee may safely receive this care in another setting. 
 
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 does not require services at a LTACH that are not already available at 
the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44204 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 44204. You say that the service at issue has been billed correctly. 
The Plan denied your request. The Plan says the available records do not support the service at issue. 
 
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 44204 is: Laparoscopy, surgical; colectomy, partial, with 
anastomosis. 
 
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 44204. Our reviewer says that procedure 
code 44204 does not meet criteria for payment. Our reviewer found that the medical records provided do not 
include sufficient documentation to validate that a Laparoscopy, surgical; colectomy, partial, with anastomosis 
was performed on March 22, 2022; therefore, this procedure cannot be verified. 
 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 44204 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 44204 billed for date of service March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. 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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the volume is somewhat more complex than a case where just the spine or rib 
would be treated such that 3D radiation is plausibly needed over 2D radiation. However, the need for IMRT is 
not justified based upon quantifiable dosimetric measures or a plausible rationale. ASTRO model policy 
emphasizes the need to support IMRT with dosimetry; this would be of particular importance for clinical 
scenarios for which IMRT is not considered standard. IMRT would not be furnished in accordance with 
accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity modulated radiation therapy (IMRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798 and 87641 
billed for date of service February 9, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653, 87798 and 87641. You say that these 
services are supported in the medical record. The Plan denied your request. The Plan says payment for codes 
87150, 87481, 87653, 87798 and 87641 is bundled into the payment for codes 87500, 87150 and 87801. 
 
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 87150 
is a column II code to column I code 87500, and codes 87481, 87653, 87798 and 87641 are column II codes to 
column I codes 87150 and 87801. 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 codes 87150, 87481, 87653, 87798 and 87641 billed for date of service 
February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (26123) provided June 2, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 26123 is Fasciectomy, partial palmar with release of 
single digit including proximal interphalangeal joint, with or without Z-plasty. 
 
We find that CPT code 26123 is not supported in the medical record. Specifically, release of the proximal 
interphalangeal joint cannot be verifed, as this procedure is not documented in the operative report. Based on 
this information, we decided that Medicare rules for coverage of the surgical services have not been met. 
Therefore, we decided that the Plan does not have to pay for surgical services (26123) provided June 2, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital care billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for the billed services. You say that reconsideration is requested for medical 
necessity. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code G0463 was billed on the same day as code 71260, which has a status indicator of S. If 
any E&M code that occurs on a day with a type S procedure does not have a modifier of 25, then the claim is 
returned to the provider. In this situation, code G0463 was not billed with modifier 25 as required.  
 
We find that codes Q9967 and 71260 were denied as errors on other claim lines need to be corrected. These 
line items may be eligible for payment when a corrected claim is submitted. We find that CPT code G1004 is 
not paid by Medicare when submitted on outpatient claims. 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 the outpatient hospital care billed for date of service July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
August 23, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this testing was medically necessary for this 
enrollee. The Plan denied your request. The Plan says the enrollee has had this same test performed by the 
same provider, which was billed for date of service July 11, 2022, and has already been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that NGS tests are not covered for patients who have previously 
received the same test for the same cancer. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F1CDx testing have not been met. Specifically, the record shows that the same enrollee has had 
this test previously. This previous test was performed by the same provider and billed for date of service July 
11, 2022. The record shows that the Plan paid this previous claim on August 4, 2022. This test is not covered 
twice for the same cancer. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx 
(F1CDx) (0037U) testing provided on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in iVAPS mode with Auto-
expiratory positive airway pressure (EPAP) (AE) that could be delivered by bilevel positive airway pressure 
(BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found poducts currently classified as HCPCS code E0466, when used to provide CPAP or bi-level 
PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in 
the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in 
this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP 
(E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in the Medicare RAD policy will be denied as not 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve multiple procedures on the left leg tibial arteries including 
angioplasty, atherectomy, or stents. 
 
You asked the Plan to pre-approve multiple procedures on the left leg tibial arteries. 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 PTA is covered when used under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve multiple procedures on the left leg tibial 
arteries. Our reviewer says that the services are medically necessary. Our physician reviewer found the 
documentation meets coverage criteria and supports the medical necessity of the procedures in question. 
Review of the records suggest that the enrollee has severe iliac and proximal femoral arterial occlusive disease 
with progressively worsening claudication, most recently noted to be much less than 2 blocks. Based on the 
degree of occlusion as well as the proximal nature of the occlusive disease is not expected that the enrollee 
would improve with conservative treatment, and claudication due to inflow disease is particularly disabling. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multiple procedures on the left leg tibial arteries have been met. Therefore, we 
decided that the Plan has to pre-approve multiple procedures on the left leg tibial arteries including angioplasty, 
atherectomy, or stents.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of SNF care is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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. The Plan denied your request. The Plan says with 
additional time in the current setting, the enrollee's clinical stability may be ensured such that the appropriate 
lower level of care can be determined. 
 
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 does not require services at the LTACH that are not already available at 
the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle test strips. 
 
You asked the Plan to pre-approve Freestyle test strips. You say that you cannot use the covered test strips. 
You say that you are allergic to the glue that is used for the adhesives. The Plan denied your request. The Plan 
says the requested test strips are not covered. You are required to try and fail the covered alternatives before the 
plan can cover the requested product or your doctor needs to provide a clinical reason for why you cannot use 
the covered alternatives. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 We looked at the file and Medicare rules. The records do not indicate that you have tried and failed the covered 
alternatives. Your doctor did not provide documentation indicating you have tried and failed the covered 
alternatives or a clinical reason for why you are unable to use the covered alternatives. Based on this 
information, we decided that Medicare rules for coverage of Freestyle test strips have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Freestyle test strips.