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

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESIs) (64483, 64484). 
 
You asked the Plan to pre-approve the ESIs. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the requested injections are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the requirements are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ESIs. Our reviewer says that the 
requested ESIs are not medically necessary. Our physician reviewer found the provided documentation does 
not support that the enrollee has radiculopathy, radicular pain and/or neurogenic claudication is severe enough 
to greatly impact quality of life or function. The reviewer found that the enrollee's pain is reportedly a one out 
of ten. Therefore, the reviewer found that the requested injections are not 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 the ESIs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve epidural steroid injections (ESIs) (64483, 64484).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 11103 and 17003 billed for date of service 
July 27, 2022. 
 
You asked the Plan to pay for procedure codes 11103 and 17003. The Plan denied your request. The Plan says 
payment for codes 11103 and 17003 is bundled into payment for code 17110.  
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 codes 
11103 and 17003 are column II codes to column I code 17110. 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 11103 and 17003 billed for 
date of service July 27, 2022.
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 August 29, 
2022. 
 You asked the Plan to pay for procedure code 97110. You say that this service was reported correctly with the 
GP modifier as this was performed under a physical therapy plan of care. The Plan denied your request. The 
Plan says this service was billed with an incompatible modifier and revenue code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that outpatient rehabilitation claims must include the GN, GO or GP modifier to distinguish the 
discipline of the plan of care under which the service is delivered. The rules say that services billed with the GP 
modifier may only be billed with revenue code 42x. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, this service was billed with 
the GP modifier but was billed with revenue code 410, which is not a 42x (physical therapy) revenue code. 
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 August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Harmar SL300 complete stairlift (E1399) and repair or 
nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a 
technician, labor component, per 15 minutes (K0739). 
 
 
 
 You asked the Plan to pre-approve a stair lift and labor. You say that the requested stair lift is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the notes provided show that the 
enrollee is able to ambulate with a wheeled walker. The enrollee does not require to lie face up for transfers. 
Additionally, the provider has requested this stair lift using the miscellaneous code E1399. Medicare does not 
allow for miscellaneous codes to be submitted for payment when there is a valid HCPCS code for the device. 
 
The Plan covers all items that Medicare covers. Medicare rules state that a patient lift is covered if transfer 
between bed and a chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary 
would be bed confined. 
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
The records show the enrollee can ambulate with a wheeled walker. The enrollee is not confirmed to a bed. 
Medicare does not consider a stair lift to  be durable medical equipment as it does not service a medical 
purpose. Therefore, we decided that the Plan does not have to pre-approve a Harmar SL300 complete stairlift 
(E1399) and repair or nonroutine service for durable medical equipment other than oxygen equipment requiring 
the skill of a technician, labor component, per 15 minutes (K0739).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic eye exam (92004), and fundus photography 
(92250), provided on October 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that you were not aware the provider was out-of-
network. The Plan denied your request. The Plan says the provider was out-of-network. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the diagnostic eye exam (92004), and fundus 
photography (92250), provided on October 25, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator.  
You asked the Plan to pre-approve a peripheral nerve stimulator. You say that the enrollee has tried 
pharmacologic medications, physical therapy and home therapy. The Plan denied your request. The Plan says 
the criteria for coverage 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 a peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested procedure is considered experimental for chronic low 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 a peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peripheral nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special supplemental benefit for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you disagree with the denial. The Plan denied 
your request. The Plan says there is no documentation that the enrollee meets criteria for the requested benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve a special supplemental benefit for the chronically ill (SSBCI).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 22, 2022, to 
February 20, 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 January 22, 2022, to 
February 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 16, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on August 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99000 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 99000. The Plan denied your request. The Plan says procedure 
code 99000 is considered bundled and 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 procedure code. 
 We find that procedure code 99000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99000 billed for date of service July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization services represented by codes 37220, 
37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, and 37231. 
 
You asked the Plan to pre-approve the revascularization services. You say that the records provided support the 
need for the services in dispute. The Plan denied your request. The Plan says the requested services are not 
medically necessary for the enrollee's condition. 
 
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 revascularization services. Our 
reviewer says that the requested revascularization services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a history of arthritis and renal 
insufficiency.  There are conflicting elements in the medical record ranging from 'the enrollee's right leg feels 
better' to 'short distance claudication.'  However, there is no documentation that the enrollee is having signs of 
limb threat.  It is unclear if the enrollee is having lifestyle limiting claudication.  The pulse examination is 
incomplete, and ankle-brachial indexes (ABIs) are not provided.  
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 revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization services represented by codes 37220, 37221, 37224, 
37225, 37226, 37227, 37228, 37229, 37230, and 37231.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is an excellent candidate for acute 
inpatient rehab. You say the enrollee requires and can tolerate three hours daily of physical and occupational 
therapy and will benefit from acute rehabilitation to restore functions for a safe return home in a reasonable 
period of time. The Plan denied your request. The Plan says based on Medicare guidelines, 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they would meet criteria for admission to an 
acute inpatient rehabilitation facility. The enrollee can receive further services at 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service October 8, 
2022. 
 
You asked the Plan to pay for procedure code S9328. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service October 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0861) and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that this 
wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is covered when medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested power wheelchair is not medically necessary. Our 
physician reviewer found the provided records do not document the patient has a musculoskeletal condition or 
the presence of a cast or brace which prevents 90-degree flexion at the knee or the patient has significant edema 
of the lower extremities that requires an elevating leg rest. Provided records do not support that the patient is 
high risk for skin breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. Records do not 
document that she performs bladder self-catheterization and is unable to transfer independently. 
 
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 group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options (K0861) and accessories.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided from September 6, 2022, to 
September 30, 2022. 
 
You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says the claim was 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that a GN, GO or GP modifier should be present for 
all lines reporting revenue codes 042X, 043X, or 044X  
 
We looked at the file and Medicare rules. In this case, claim line 1 was not reported with the appropriate 
modifier GP. As such, the entire claim has been denied and returned to the provider. Based on this information, 
we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided 
that the Plan does not have to pay for the therapy services provided from September 6, 2022, to September 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visit (99214) provided on September 7, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the claim was not billed 
with the appropriate modifier.  
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. Medicare rules also say that carriers pay for an evaluation and management service on 
the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT 
modifier "-57" to indicate that the service resulted in the decision to perform the procedure. 
 
We looked at the file and Medicare rules. Payment for the requested services (99214) is included in the global 
surgery payment for the procedure (66821) provided on September 8, 2022, which has a 90-day global period. 
The claim was not billed with modifier -57 for payment to be considered. Based on this information, we 
decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan 
does not have to pay for the visit (99214) provided on September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral liquid nutrition supplement with Nepro (B4154). 
 
You asked the Plan to pre-approve Nepro. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that orally administered enteral nutrition products, 
related supplies and equipment will be denied non-covered, no benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Nepro have not been met. Therefore, we decided that the Plan does not have to pre-approve an oral 
liquid nutrition supplement with Nepro (B4154).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that based on the enrollee's current condition, functional 
deficits, and multiple comorbidities, the enrollee meets full IRF criteria. The Plan denied your request. The 
Plan says criteria for admission to the IRF have not been met. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they would meet criteria for admission to an 
acute inpatient rehabilitation facility. The enrollee can receive further services at 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.