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

 
We decided that the Plan does not have to pre-approve physical therapy and speech therapy to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy and speech therapy to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy and speech therapy to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for dates of service from April 
26, 2022, to April 27, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the available records do not support the services 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 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 procedure 
code 99233 does not meet criteria for payment. Our reviewer found that the evaluation and management code 
at issue requires two out of these three key components: a detailed interval history, a detailed examination and 
medical decision making of high complexity. In this case, the medical records submitted did not support a 
detailed interval history and medical decision making of high 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 procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 billed for dates of service from April 26, 2022, to April 27, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound polymerase chain reaction (PCR) panel (87651, 
87500, 87640, 87481) provided on September 6, 2022. 
 
You asked the Plan to pay for a wound PCR panel. You say that this testing was medically reasonable and 
necessary. The Plan denied your request. The Plan says this panel exceeds the enrollee's medical needs. 
 
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 pay for a wound PCR panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the longstanding standard of care for the evaluation of bacteria or fungus in a wound is to 
perform a deep culture swab and or send a small specimen of the ulceration for culture and sensitivity, KOH, 
and fungal culture. These laboratory tests are inexpensive, sensitive, and specific. It is unclear as to why this 
enrollees ulceration specimen required PCR testing as compared to standard culture and sensitivity, KOH, or 
fungal culture. Therefore, the PCR testing of this enrollees ulceration specimen was not medically reasonable 
or necessary at this time. 
 
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 wound PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for a wound polymerase chain reaction (PCR) panel (87651, 87500, 87640, 87481) 
provided on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the catheter supplies provided on August 26, 2022, and October 3, 
2022. 
 
You asked the Plan to pay for the catheter supplies. You say that you have had very much trouble getting the 
Plan to pay these claims which are regularly paid without issue by the Medicare contractor. The Plan denied 
your request. The Plan says that these services are not payable as the Physician Fee Schedule indicator is P, 
which means payment is included in payment for other services. In addition, there is no order or proof of 
delivery included. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a valid denial rationale in this case. The Plan's 
rationale is based on the status indicator in the Physician Fee Schedule. However, this item is covered as 
Durable Medical Equipment (DME). This is payable on the DME Fee Schedule. We verified on the 
Medicare.gov website that the provider is a Medicare-enrolled DME supplier. Though the Plan does indicate 
that proof of delivery and an order were not submitted, this was not the reason for the claim denial, and the 
Plan has not provided evidence that these documents were requested from the supplier. We find that the denial 
of payment for these items is not substantiated. Therefore, we decided that the Plan has to pay for the catheter 
supplies provided on August 26, 2022, and October 3, 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 pay for inpatient hospital services provided on May 21, 2022, to 
May 26, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis code A41.9, described as sepsis, 
unspecified organism. 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 documentation does not support the billed code. 
Our physician reviewer found the enrollee is an 89-year-old female who presented with fever, erythema right 
arm from a cat scratch requiring antibiotics. Initially she had a low-grade fever, leukocytosis, but had normal 
bilirubin, normal creatinine, normal platelets, was not hypoxic, and was alert and oriented without distress. 
Blood cultures were negative. These signs suggest an infection was present but was not systemic and that it did 
not lead to a dysregulated response causing organ failure which is required to meet Sepsis 3 criteria.  
 
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 May 21, 2022, to May 26, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
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 as the enrollee is declining 
and at risk of falling and injuring themselves. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 procedure code 58300. 
 
You asked the Plan to pre-approve procedure code 58300. You say that the services are necessary. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 58300 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code 58300 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 58300 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve procedure code 58300.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on June 
1, 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 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 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 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 in this case, the documentation 
doesnt support the CPT code 99223. The documentation available for review does not support the encounter 
required decision making of high 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 initial hospital care (procedure code 99223) rendered on June 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS device. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. 
 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a CardioMEMS device (33289).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95885, 95911 and 95937 billed for date of 
service November 16, 2022. 
 
You asked the Plan to pay for procedure codes 95885, 95911 and 95937. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these codes are 
not supported in the medical record. 
 
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 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 codes 95885, 95911 and 95937. Our reviewer says 
that these services are not supported in the medical records provided. Our reviewer found the procedure report 
does not support nerve conduction studies, as pedicle screw stimulation was documented, therefore this procedure cannot be verified. The described pedicle screw stimulation would not be reported with nerve 
conduction (measures amplitude, latency/velocity) therefore, this procedure cannot be verified. In addition, the 
procedure report documents "Train-of-Four Neuromuscular Junction testing was performed to verify the 
validity of monitoring procedures dependent upon active motor neuronal firing, such as electromyography and 
motor evoked potentials monitoring and/or pedicle stimulation." In this case, this procedure cannot be verified, 
as train of four and neuromuscular junction testing is two separate procedures. Train of four testing is included 
in the primary neuromonitoring procedure. Therefore, the reported procedures cannot be verified. 
 
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 codes 95885, 95911 and 95937 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 95885, 95911 and 95937 billed for date of 
service November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 12, 2022. 
 
You asked the Plan to pay for the testing services. You say that the claim should be paid at the established rate. 
The Plan denied your request. The Plan says the claim 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 testing services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on October 12, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the criteria for 
approval have not been met. 
 
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 a computed tomography (CT) scan. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has known 
rectal carcinoma with metastatic disease. Two new nodules are being followed in the chest and patient is on 
chemotherapy. 
 
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 computed tomography (CT) scan have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan.  
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is weak, has continuous falls, and is in 
desperate need of IRF services to build strength and mobility. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements 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 that 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. The 
enrollee has a past medical history of chronic obstructive pulmonary disease (COPD) and is living at home 
with frequent falls. The enrollees medical problems are stable and 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 enrollee 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 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 an IRF admission and services.