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

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on September 14, 2022, billed with code 99223. 
 
You asked the Plan to pay for the EM services as billed. You say that the code billed is correct and should be 
paid. The Plan denied your request. The Plan says the records do not support the services 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 EM services as billed. Our reviewer says 
that the EM code billed is not supported by the records. Our reviewer found the enrollee presented to the 
hospital with malaise and weakness and a reported sodium of 124. He has had multiple admissions for this 
where he gets intravenous fluids which resolves the hyponatremia temporarily. His examination was detailed, 
but not comprehensive and history was focused, not comprehensive. Also, the decision-making was not high 
complexity but was rather routine and simple with the enrollee being medically stable. Therefore, the code, 
99223 is not supported in the documentation.  
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient evaluation and management (EM) services provided on September 
14, 2022, billed with code 99223.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code L8614 billed for date of service November 
22, 2022. 
 
You asked the Plan to pay for procedure code L8614. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code L8614 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 L8614 has a status indicator of N on the Outpatient Prospective Payment System. 
This means that procedure code L8614 is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure code L8614 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code L8614 billed for date of service November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zinger power foldable chair. 
 
You asked the Plan to pre-approve a Zinger power foldable chair. You say that your previous wheelchair was 
stolen. You also say that you would like it to be replaced with a different type of chair that better fits your 
needs. The Plan denied your request. The Plan says the documentation does not support that the requested item 
is needed for use inside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Zinger power foldable chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0202U) provided on December 5, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0202U) 
provided on December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the oxygen. You say that you are requesting a battery-operated portable 
oxygen system so you can move more easily around your house and outside your house so you can take the 
garbage out and other tasks like gardening. The Plan denied your request. The Plan says the supplemental 
oxygen delivered in December 2022 continues to meet the medical need in the home. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have oxygen concentrator (E1390) portable gas oxygen system (K0738) and oxygen 
conserving device. The standard portable oxygen system, the oxygen conserving device was provided on 
December 21, 2022. The oxygen conserving device serves the same purpose as the portable oxygen. Therefore, 
we decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the cervical spine without contrast. 
 
You asked the Plan to pre-approve CT scan of the cervical spine without contrast. You say that the enrollee 
needs a CT scan of the neck spine without dye. The Plan denied your request. The Plan says the enrollee does 
not have symptoms or exam results to support the requested imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan of the cervical spine without 
contrast. Our physician reviewer found the medical records did not show that there were any signs or 
symptoms related to the cervical spine. The requested CT scan is 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 CT scan of the cervical spine without contrast have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CT scan of the cervical spine without contrast.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the open implantation of hypoglossal nerve 
neurostimulator array, pulse generator and distal respiratory sensor electrode or electrode array (64582). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you humbly implore the Plan to reverse 
its decision and help you one last time to try and alleviate your medical condition. The Plan denied your 
request. The Plan says the enrollee does not meet medical necessity criteria. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that the implantation of hypoglossal nerve neurostimulator 
at issue in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. The 
provided records in this case do not document CPAP failure (defined as AHI greater than 15 despite CPAP 
usage) or CPAP intolerance (defined as less than 4 hours per night, 5 nights per week or the CPAP has been 
returned) including shared decision making that the patient was intolerant of CPAP despite consultation with a 
sleep expert. The provided records do not detail what adjustments to the CPAP equipment were tried and failed 
to determine that the enrollee is completely intolerant to it. The enrollees latest sleep study summary 
recommended CPAP therapy as the treatment of choice with behavioral treatment (weight optimization, avoid 
supine sleep position and pre-sleep alcohol) along with consideration of ear, nose and throat evaluation for 
possible surgery or dental evaluation for oral appliance therapy. The provided records do not document failure 
of these recommended interventions. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the open implantation of hypoglossal nerve neurostimulator array, pulse generator 
and distal respiratory sensor electrode or electrode array (64582).
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 enrollee needs IRF care. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting 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 the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture and mandibular complete 
denture. 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures do not fit, and you 
are not able to eat. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 27, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture and mandibular 
complete denture.
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 IRF is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.  
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for LTACH services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided from September 9, 2022, to 
September 11, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
code 99233. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99233. 
 
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 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99233. Our reviewer says that the medical 
records do not support the billing of code 99233. Our reviewer found the enrollee was treated on September 9, 
10, and 11, 2022. She was hospitalized with acute on chronic epigastric pain and right chest pain and was 
treated with pain medication, muscle relaxants. Workup was essentially unremarkable. The notes for the dates 
listed above included only focused, brief histories and physical examinations were not detailed. The enrollee 
was stable, and treatment was not complex. There was no evidence to suggest decision-making was of high 
complexity for any of the dates listed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 provided from September 9, 2022, to September 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided on November 3, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) as a 
diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical 
Laboratory Improvement Amendments (CLIA)- certified laboratory, when ordered by a treating physician, and 
when the test has Food & Drug Administration (FDA) approval or clearance as a companion in vitro 
diagnostic; and, an FDA-approved or cleared indication for use in that patients cancer. 
 
We looked at the file and Medicare rules. The test at issue, Tempus Liquid CGP panel, has not had FDA 
approval or clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pay for genetic testing (81455) provided on November 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of an intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628, 64629). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plans 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that magnetic resonance imaging (MRI) results show foraminal stenosis. The cause of the enrollee's back 
pain is unclear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of an intraosseous basivertebral nerve, including all imaging guidance; 
first 2 vertebral bodies, lumbar or sacral (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-segmented pneumatic compressor (E0650). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that the enrollee was treated for 
post-surgical venous thromboembolism prophylaxis. You disagree with this denial and believe the services 
were medically necessary. The Plan denied your request. The Plan says pneumatic compression devices are not 
covered by Medicare for to prevent deep vein thrombosis during and/or following surgery. Items that are meant 
for prevention are not covered. 
 The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve non-segmented pneumatic 
compressor (E0650).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two levels of bilateral Medial Branch Blocks (MBBs). 
 
You asked the Plan to pre-approve MBBs. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions such as Medial Branch 
Blocks (MBB are considered medically reasonable and necessary for the diagnosis and treatment of chronic 
pain when there is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
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 MBBs. Our reviewer says that the 
requested MBBs are not medically necessary. Our physician reviewer found the enrollee has radiculopathy and 
there is non-facet pathology that could explain the source of the enrollee's pain. The submitted Magnetic 
Resonance Imaging (MRI) shows severe right-side stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MBBs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve two levels of bilateral Medial Branch Blocks (MBBs).