Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for bradycardia, pneumonia, and cellulitis. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 is living at home with myopathy and progressive weakness and frequent 
falls. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
Kit 2 Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM Kit 2 Sensor. You say that the enrollee is diagnosed 
with prediabetes. The provider recommends glucose monitoring to help prevent him from being diabetic. The 
Plan denied your request. The Plan says a CGM is not covered under Medicare if the enrollee is not diagnosed 
with diabetes mellitus and is not on insulin. 
 
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 indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre CGM Kit 2 Sensor have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) Kit 
2 Sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 43235, 44810, and 49905 provided to the 
enrollee on October 12, 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 the denied codes are not supported in the records submitted. 
 
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 49905: 
 
Omental flap, intra-abdominal (List separately in addition to code for primary procedure) 
 
CPT 43235: 
 
Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 
 
CPT 44180: 
 
Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure) 
 
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 operative report does not 
include documentation to confirm that CPT 49905 was rendered in this case. Additionally, in terms of CPT 
43235, the operative report includes documentation of a diagnostic esophagogastroduodenoscopy, flexible, 
however a more comprehensive procedure was performed, surgical laparoscopic sleeve gastrectomy was 
performed. Therefore, CPT 43235 would not be billed separately. Finally, in terms of CPT 44180, the provider 
performed a gastrectomy, which is a more comprehensive procedure. In this case, CPT 44180 would not be 
reported separately. 
 
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 procedure codes 43235, 44810, and 49905 provided to the enrollee on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99205) rendered on May 9, 
2022. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says the documents do not support this level of care. 
 
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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter." 
 
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 visit. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the enrollee received a new patient 
evaluation for a problem-focused complaint (cataract). A comprehensive eye exam was performed. Straight-forward medical decision making occurred. The amount of time spent caring for the patient is not 
documented. As such, the billing of CPT 99205 is not supported. 
 
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 visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit (procedure code 99205) rendered on May 9, 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 you need inpatient rehabilitation facility admission. 
The Plan denied your request. The Plan says your records show you do not require an intensive and coordinated 
interdisciplinary approach to your rehabilitation, medically necessary care may be provided safely in a different 
level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 pay for procedure code(s) 93971 billed for date of service April 16, 
2022. 
 You asked the Plan to pay for procedure code(s) 93971. You say that this service is supported as billed. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 93971. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 93971. Based on this information, 
we decided that Medicare rules for coverage of procedure code 93971 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 93971 billed for date of service April 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87641) provided on November 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for code 87641 (Infectious agent detection 
by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique) 
services are not payable under Medicare Part B for screening purposes and will be denied. 
 
We looked at the file and Medicare rules. This service is non-covered. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services (87641) provided on November 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 02, 2021, 
through June 07,2021, and billed with primary diagnosis code A419 and secondary diagnosis codes R65.20 and 
J69.0. You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis code A41.9 and secondary diagnosis codes R65.20 and J69.0 is supported by the records. The Plan 
denied your request. The Plan says the documentation submitted does not support primary diagnosis of A41.9 
and secondary diagnosis of R65.20 and J69.0. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A419, sepsis, secondary 
diagnosis code R65.20-severe sepsis without septic shock, and secondary diagnosis code J69.0-pneumonitis 
due to inhalation of food and vomit. We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that the documentation does not 
support primary diagnosis code A41.9, Sepsis, secondary diagnosis code R65.20 representing severe sepsis 
without septic shock, and Secondary diagnosis code J69.0 representing pneumonitis due to inhalation of food 
and vomit. Our physician reviewer found the member's presentation warranted consideration of sepsis as a 
possible diagnosis and a localized infection of pneumonia was identified however, the diagnosis of sepsis was 
not supported by the clinical evidence. Which in turn does not support secondary diagnosis code R65.20-
Severe sepsis without septic shock and secondary diagnosis code J69.0- pneumonitis due to inhalation of food 
and vomit. Therefore, diagnosis code A41.9 is not the appropriate primary diagnosis code and diagnosis codes 
R65.20 and J69.0 are not the appropriate secondary diagnosis codes.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 02, 2021, through June 07,2021, and billed with primary 
diagnosis code A419 and secondary diagnosis codes R65.20 and J69.0.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve facet joint RFA. 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 follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet specific criteria. 
 
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 facet joint RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found thoracic facet blocks are not indicated 
here. Neurolysis of the intercostal nerves would be medically indicated. However as requested, the procedures 
are not medically reasonable or 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 facet joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on April 25, 2022. 
 
You asked the Plan to pay for subsequent hospital care (99231). The Plan denied your request. The Plan says 
no medical records were submitted to determine if the claim should be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of subsequent hospital care (99231) have 
been met. Specifically, medical records were not submitted. Therefore, we decided that the Plan does not have 
to pay for subsequent hospital care (99231) provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed on April 7, 2022. 
 
You asked the Plan to pay for procedure code 99213. You say that the procedure code indicates the enrollee 
was an outpatient. You say that the documents should be reviewed, and the claim reprocessed for payment. The 
Plan denied your request. The Plan says POS 21 is not valid for telehealth visits. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  We find that CPT code 99213 is not supported in the medical record. Specifically, the inpatient POS was billed, 
but the records show a telehealth visit was performed. Based on this information, we decided that Medicare 
rules for coverage of the telehealth visit have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 99213 billed on April 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 31, 2022 to 
September 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. 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 August 31, 2022 to 
September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99205 billed for date of service October 8, 2022. 
 
You asked the Plan to pay for code 99205. You say that you believe the Plan underpaid your claim. The Plan 
denied your request. The Plan says this service was billed incorrectly. 
 
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 99205 is office or other outpatient visit for the evaluation 
and management of a new patient. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, you billed a code 
representing a new patient visit.  Medicare rules say that the term "new patient" means a patient who has not received any professional services from the physician or physician group practice within the previous three 
years. In this case, the records show that this patient had already received services from another provider within 
the same physician group on October 2, 2022.  This is within this 3-year window, so a 'new patient' visit should 
not have been billed for the services on October 8, 2022. Based on this information, we decided that Medicare 
rules for coverage of code 99205 have not been met. Therefore, we decided that the Plan does not have to pay 
for code 99205 billed for date of service October 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on May 10, 
2022. 
 
You asked the Plan to pay for the MRI. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the services are not payable as 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 73721 is magnetic resonance (eg, proton) imaging, any 
joint of lower extremity; without contrast material. 
 
We find that CPT code 73721 is not supported in the medical record. Specifically, an anatomic modifier was 
not billed with this code. This means the claim is not payable as billed. Based on this information, we decided 
that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not 
have to pay for the magnetic resonance imaging (MRI) provided on May 10, 2022.