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

 
We decided that the Plan does not have to pay for hospital care (procedure codes 99223 and 99232) rendered 
on April 17, 2022, and April 18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99223 and 99232 remains not supported. 
 
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 the denied codes is: 
 
CPT 99223: 
 
Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which 
requires a medically appropriate history and/or examination and high level of medical decision making. When 
using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded 
 
 CPT 99232: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using total time on the date of the encounter for code selection, 35 minutes must be met or 
exceeded 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records did not support that 
CPT 99223 was rendered in this case. The records did not support a comprehensive history and exam. In 
addition, the records did not support that there was medical decision making of high complexity on April 17, 
2022. In terms of CPT 99232 on April 18, 2022, it was not supported in the records. There was no expanded 
problem-focused interval history and decision making of moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital care (procedure codes 99223 and 99232) rendered on April 17, 2022, and April 18, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
(power tilt) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with single power option and accessories.. You 
say that the enrollee requires power mobility to access home environment safely. The Plan denied your request. 
The Plan says the enrollee does not have medical need for single power options included with group 3 power 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered if certain 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 a Group 3 power wheelchair with single 
power option and accessories. Our reviewer says that the enrollee does not meet the Medicare criteria for the 
requested Group 3 power wheelchair with single power option. Our physician reviewer found the records do 
not support that the enrollee is at high risk for skin breakdown, does not require intermittent catheterization and 
does not have spasticity. The enrollee has adequate strength to use standard switches on a power wheelchair. 
 
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 single power option and accessories. have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with 
single power option (power tilt) and accessories.
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. The Plan denied your request. The Plan says criteria for admission 
to the Acute Inpatient Rehabilitation setting have not been met, the enrollee's ongoing skilled therapy and 
nursing needs can be provided at a lower level of care, at a Skilled Nursing Facility, on an intermittent basis at 
home with home health care, or in a long-term care setting. 
 
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 document does not support necessity for admission to an IRF and the complexity of 
the enrollee's therapy, nursing, and medical needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitative 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a screening computed tomography (CT) colonography 
(74263). 
 
You asked the Plan to pre-approve a screening CT colonography. You say that the enrollee was unable to finish 
prep to be able to look into the colon and there was a moderate amount of stool in the rectum which made 
visibility difficult. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for 
the requested service. 
 
The Plan follows Medicare rules. Medicare rules say that CT colonography can be covered when certain 
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 a screening CT colonography. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record describes a 
colonoscopy that was complete to the ileum in May 2018, and a second colonoscopy attempted in October 
2022, but limited due to poor colonic preparation. No formal procedure reports were provided to support any of 
the contraindications listed per LCD criteria. The enrollee has chronic constipation with pelvic floor 
dysfunction but has demonstrated that she can achieve an adequate bowel cleansing to effect a completed 
colonoscopy testing. 
 
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 screening CT colonography have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a screening computed tomography (CT) colonography (74263).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the denial. The Plan 
denied your request. The Plan says the documentation does not support the coding. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
at minimum, 15 drug classes were tested. The records show that several of the drugs tested belonged to the 
same drug class. 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 G0482 billed 
for date of service August 25, 2022.
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 the requested IRF services are necessary to get you 
back to a productive life. 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 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: 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 would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee can get the services they need in other settings. 
 
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 enrollee does not have any complex functional deficits or active medical 
issues. The enrollees needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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: 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 the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the requested LTACH services do not meet the 
requirements for approval. 
 
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 Plan has approved ongoing care in the 
current acute care setting. 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: 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 care for yourself and would not be able to 
function with daily living things, cannot get to and from appointments and decreased mobility and 
independence. You need intense therapy, function is declining level of function, need help with simple tasks. 
The Plan denied your request. The Plan says your records do not show you need and are able to take part in 3 
hours of therapy a day at least 5 days a week or 15 hours per week, services needed can be provided safely in 
other settings, a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 your functional status does not require intensive rehabilitation you do not tolerate 
ambulation and remainder of mobility skills are able to improve with repetitive exercise and support. You do 
not have significant barriers to stand post-acute rehabilitation and do not require frequent physiatry oversight. 
 
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: 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. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for an inpatient rehabilitation facility. 
 
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 clinical documentation does not completely specify functional impairments or skilled 
therapy needs and no active medical issues are documented.  
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 group 3 power wheelchair (K0856), power seating 
system, tilt only (E1002), manual swingaway (E1028), 22nf sealed lead acid battery (E2361), cushioned 
headrest (E0955), and skin protection and positioning wheelchair seat cushion (E2607). 
 
You asked the Plan to pre-approve a group 3 power wheelchair, power seating system, tilt only, and 
accessories. You say that based on the Medicare LCD, and the enrollee's diagnosis with a neurological 
condition, the enrollee qualifies for the group 3 power wheelchair. The Plan denied your request. The Plan says 
the requested group 3 power wheelchair with tilt only seating, including accessories, are not shown to be 
medically necessary per Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with power seating 
system, tilt only, may be covered if certain 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 a group 3 power wheelchair, power 
seating system, tilt only, and accessories. Our reviewer says that the group 3 power wheelchair with power tilt 
is not medically necessary. Our physician reviewer found the clinical documentation is insufficient as to why a 
lower-level power wheelchair would not suffice for the enrollee's needs versus a group 3 power wheelchair. 
There is also inadequate clinical documentation regarding why the enrollee requires power tilt and cannot 
perform pressure relief. Our reviewer found that the clinical progress note indicates that the enrollee has 5 out 
of 5 motor strength in the upper extremities and that they are independent with their daily activities. Our 
reviewer also found that the enrollee should be able to independently perform pressure relief, is not at high risk 
for skin breakdown, and does not have impaired sensation. 
 
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, power seating system, tilt only, and accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair (K0856), power seating system, tilt only (E1002), manual swingaway (E1028), 22nf sealed lead 
acid battery (E2361), cushioned headrest (E0955), and skin protection and positioning wheelchair seat cushion 
(E2607).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis, L1810, billed for date of service August 
24, 2022. 
 
You asked the Plan to pay for the billed services. You say that records were provided for review. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The records provided show that an orthosis identified by code 
L1820 was provided. Based on this information, we decided that the Medicare rules for coverage have not been 
met. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the knee orthosis, L1810, billed for date 
of service August 24, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 76770. We decided that the Plan does not have to pay for 96372.  
 
You asked the Plan to pay for procedure codes 76770 and 96372 rendered on October 12, 2022.. You say that 
medical records were submitted for review. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 76770.  
 
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 CPT 76770 is "Ultrasound, retroperitoneal (eg, renal, aorta, 
nodes), real time with image documentation; complete." 
 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 for CPT 76770. Our reviewer says that the 
performance of a retroperitoneal ultrasound is confirmed by the report authorized by the doctor. It includes all 
the appropriate structures necessary to qualify for CPT 76770. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
76770.  
 
We also decided that the Plan does not have to pay for 96372. 
 
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 CPT 96372 is "Therapeutic, prophylactic, or diagnostic 
injection (specify substance or drug); subcutaneous or intramuscular." 
 
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 for CPT 96372. Our reviewer says that this code 
should be considered part of the global procedure for CPT 52224. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 96372 have not been met. Therefore, we decided that the Plan does not have to 
pay for 96372. 
 
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.