Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 14, 
2022. 
 
You asked the Plan to pay for procedure code 99285. You say that this code was billed correctly and is 
supported in the medical record. The Plan denied your request. The Plan says the billing of code 99285 for date 
of service January 14, 2022, is not supported in the medical record because there was no immediate significant 
threat to life on hospital admission. As a result, the Plan paid code 99284 instead. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 procedure code 99285 Our reviewer says 
that code 99285 is not supported in the medical record. Our reviewer found the enrollee was a then, 71 year-old 
female with a history of hypothyroidism, chronic kidney disease Stage III, Fibromyalgia, gastroesophageal 
reflux disease, hyperlipidemia, and Meniere's disease. She presented to the emergency room on January 14, 
2022, with chest pain. The evaluation revealed stable vital signs; her electrocardiogram was normal and 
computed tomographic angiography was negative for pulmonary embolism. She was observed and discharged 
home lather the same day. There was no documentation of medical decision making of high complexity with 
the presenting problem(s) being of high severity and posing an immediate significant threat to life or 
physiologic function. Therefore, code 99285 was not supported in the medical record and the Plan was justified 
in downgrading the code to 99284. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 billed for date of service January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that 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. 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 your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation 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, at an 
intensive rehabilitation therapy program. You 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery 
(22869). 
 
You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested coverage for the Vertiflex superion device placement surgery 
is not approved as it was found to be experimental/investigational/unproven. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex is experimental at this time. More research is needed. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the Vertiflex superion device placement surgery (22869).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the pneumococcal vaccine (90670) provided on March 
14, 2022. 
 
You asked the Plan to hold you harmless for the vaccine. You say that you were not able to remember when 
you last received this vaccine. You say that you were not aware the vaccine was only covered once per year. 
You also say that you feel that you were misled regarding the frequency of covered pneumococcal 
vaccinations. The Plan denied your request. The Plan says that a second vaccination is allowed only after 12 
months. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the vaccine by a contract provider. The file does not show that the Plan provided notice 
that the vaccine would not be covered. Under Medicare rules, this means the vaccine is considered approved by 
the Plan. Therefore, we decided that the Plan has to hold the enrollee harmless for the pneumococcal vaccine 
(90670) provided on March 14, 2022.  
 
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: 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 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. 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy or can tolerate this therapy on an intensive IRF level. The 
enrollee's needs can be met 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 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation versus 
skilled nursing facility rehabilitation with physical, occupational and speech therapy three times a week for 
only thirty minutes each. The enrollee has rehabilitation goals to return to his daughter's home. The Plan denied 
your request. The Plan says based on Medicare guidelines the inpatient rehabilitation facility services you are 
requesting 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee does is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services with regular physician evaluation. The enrollee's care can be meat 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for single vision sphere (V2100) and frames (V2020) 
provided on  March 2, 2022. 
 You asked the Plan to pay more for single vision sphere (V2100) and frames (V2020). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says there is a $200 allowance 
every year for routine prescription eyewear. The Plan also says that you are responsible for any amount above 
the coverage limit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers certain vision care services as a supplemental (extra) benefit. This includes a $200 
allowance every year for routine prescription eyewear. The Plan contract also says that the enrollee is 
responsible for any amount above the coverage limit. 
 
We looked at the file and the Plan's rules. The record shows that the $200 allowance has been exhausted. Based 
on this information, we decided that the Plan's rules for coverage of single vision sphere (V2100) and frames 
(V2020) have been met. Therefore, we decided that the Plan does not have to pay more for single vision sphere 
(V2100) and frames (V2020) provided on  March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vacuum system and microprocessor foot: Ossur unity 
elevated vacuum system (CPT code L5781) and Ossur Proprio microprocessor foot (CPT code L5973). 
 
You asked the Plan to pre-approve the prosthesis. You say that the prosthesis is necessary. The Plan denied 
your request. The Plan says the requested prosthesis exceeds the enrollee's need. 
 
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 prosthesis. Our physician reviewer 
found the notes do not explain why only a microprocessor foot will meet your needs, as numerous K3 feet are 
available that will allow you to continue "riding motorcycles, working outdoors and going to sing Karaoke." 
No activity demands are noted that cannot be met with K3 mechanical foot. Moreover, a mechanical foot does 
not require charging, is lighter than a microprocessor foot, is less prone to water damage (as would be 
encountered in outdoor activity described by you) and corrosion, requires less maintenance and is less prone to 
damage (as would be encountered in your proposed avocational activities). The review has determined that the 
medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vacuum system and microprocessor foot: Ossur unity elevated vacuum system (CPT code 
L5781) and Ossur Proprio microprocessor foot (CPT code L5973).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you do not get the proper care at home. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that you do not have documented daily skilled nursing or skilled therapy needs at the 
time of the request. 
 
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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for femto laser provided from July 9, 2021, through July 23, 
2021. 
 
You asked the Plan to pay for femto laser. You say that this service should be covered because it was part of 
your cataract surgery. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for femto laser provided 
from July 9, 2021, through July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on August 27, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the drug testing services provided on August 27, 2021 by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a radiological examination of the chest (71045) provided on April 2, 
2020. 
 
You asked the Plan to pay for a radiological examination of the chest. You say that the claim was denied as a 
duplicate in error. The Plan denied your request. The Plan says that this claim is a duplicate of a previously 
paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. the Plan failed to show that payment was made for the 
same service to the same provider. Based on this information, we decided that Medicare rules for coverage of a 
radiological examination of the chest have been met. Therefore, we decided that the Plan has to pay for a 
radiological examination of the chest (71045) provided on April 2, 2020.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45390-59 billed for date of service January 6, 
2022. 
 
You asked the Plan to pay for procedure code 45390-59. You say that the medical documentation supports the 
billing of this code. The Plan denied your request. The Plan says the medical records do not support the billing 
of code 45390-59. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 45390-59 Our reviewer says 
that procedure code 45390-59 is not separately payable. Our physician reviewer found the medical 
documentation does not support the separate use of procedure code 45390 even with the 59 modifier. Per 
Coding Edits, providers should not report 45385 in conjunction with 45390 for the same lesion. Due to this 
coding edit, it is not correct to code 45390. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 45390-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 45390-59 billed for date of service January 6, 2022.
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 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. 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 based on the medical records provided there is no documentation that the enrollee 
requires the services on an inpatient basis, only in a skilled nursing facility setting. Records indicate the 
enrollee is tolerating and benefitting from the treatments in the acute inpatient rehabilitation facility. Records 
document improvements in the enrollee's functional status. Records document that continued services in the 
acute inpatient rehabilitation facility are appropriate until the enrollee is stable to discharge to a lower level of 
care such as home with home health services. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve POV, group 1 standard, patient weight capacity up to 
and including 300 pounds (CPT code K0800). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary because you cannot use a 
scooter or a walker. The Plan denied your request. The Plan says your mobility limitation can be sufficiently 
and safely resolved by the use of an appropriately fitted cane or walker and additional DMEs, and the use of the 
POV would thus primarily be to enable you to perform activities outside the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found there is no documentation that your mobility deficit cannot be helped by the use of a walker. A physical therapy evaluation has reported a recommendation that you would benefit from a 4 wheeled upright walker and 
that you do not appear to meet criteria for a scooter. Based on the medical records provided there is inadequate 
documentation that you have been trialed with and been found safe to operate a power mobility device. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code 
K0800).