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

 
We decided that the Plan has to pay for the telephone evaluation and management service (99443) provided on 
June 14, 2021. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that CPT code 
99443 is not the appropriate code to bill for the service documented. 
 
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 99443 is telephone evaluation and management service by a physician or other qualified health care 
professional who may report evaluation and management services provided to an established patient, parent, or 
guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M 
service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical 
discussion. 
 
We find that CPT code 99443 is supported in the medical record. Specifically, the records indicate that the 
provider spent 31 minutes non face-to-face with the enrollee. There is no evidence in the record that this 
service originated from a related evaluation and management service provided within the previous 7 days or 
leading to an evaluation and management service or procedure within the next 24 hours or soonest available 
appointment. Based on this information, we decided that Medicare rules for coverage of the telephone 
evaluation and management service have been met. Therefore, we decided that the Plan has to pay for the 
telephone evaluation and management service (99443) provided on June 14, 2021.  
 
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 enrollee's clinical condition meets full IRF 
criteria. The Plan denied your request. The Plan says the medical records do not support that the enrollee needs 
an intensive team for your 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 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: 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 patient is in urgent need of rehabilitation care. 
The Plan denied your request. The Plan says IRF care not not medically necessary and the patient can be 
managed at a lower 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for dehydration, weakness, falls, and speech problems.The patient's medical problems are stable and 
they have no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says you can be managed at a lower 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
respiratory failure and COVID-19 pneumonia. Your medical problems are stable and you have no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 semi-electric hospital bed. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
 
 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the enrollee is scheduled for glaucoma 
surgery on April 13, 2022. She has strict post-operative instructions to sleep with her head above her heart for 
six weeks; however, the records do not support that the enrollee requires positioning of the body in ways not 
feasible in an ordinary bed. She does not require frequent or immediate changes in body position. The criteria 
for coverage for the semi-electric hospital bed are not met and the services are not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a semi-electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel (81206, 81292 and 81301) provided 
on April 29, 2021. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says one CPT code must be submitted for the 
panel. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene 
CPT codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus Gene Panel have not been met. Specifically, this claim was billed with individual gene 
CPT codes. This is considered incorrect coding for the services rendered. Therefore, we decided that the Plan 
does not have to pay for the Tempus Gene Panel (81206, 81292 and 81301) provided on April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade (J1745). 
 
You asked the Plan to pre-approve Remicade. You say that you believe Remicade is appropriate and medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not have any stated 
contraindications to the preferred products, and has not tried any of the preferred agents. The Plan also says 
that a rationale is not provided for use of the non-preferred product for safety or efficacy. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Remicade. Our reviewer says that 
Remicade is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has not tried and failed the required drugs, Humira, Enbrel, Xeljanz, or Rinvoq. Our reviewer also 
found that the documentation does not support that Humira, Enbrel, Xeljanz, or Rinvoq would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade (J1745).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee needs this equipment. 
The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pay for IRF care. You say that transfer to an IRF is medically necessary for this enrollee. 
The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's 
needs can be met in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 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. 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 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SmartPill Motility Study (91112). 
 
You asked the Plan to pre-approve SmartPill Motility Study. You say that this device is FDA approved and is 
medically necessary in this case. The Plan denied your request. The Plan says while this wireless motility 
capsule (WMC) is FDA approved for evaluation of gastric emptying in gastroparesis, colonic transit in 
constipation, and evaluation of generalized dysmotility and is recognized for assessment of gut dysmotilities, it 
has not been widely accepted as standard of care in clinical practice outside of tertiary care specialty centers 
and is not more readily available than gastric motility or colon transit testing. 
 
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 SmartPill Motility Study. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Wireless Motility Capsule (SmartPill, WMC) is FDA approved for 
evaluation of gastric emptying in gastroparesis, colonic transit in constipation and evaluation of generalized 
dysmotility. The device is recognized for assessment of gut dysmotilities by both the American 
Neurogastroenterology and Motility Society as well as by the American Gastroenterology Association. However, WMC has not been widely accepted as standard of care in clinical practice outside of tertiary care 
specialty centers and is not more readily available than gastric motility or colon transit testing.   
 
The use of Wireless Motility Capsule (SmartPill, WMC) has been validated for the assessment of 
gastrointestinal transit. The normal range for transit time includes the following: gastric emptying (2-5 hours), 
small bowel transit (2-6 hours), colonic transit (10-59 hours) and whole gut transit (10-73 hours). Besides 
avoiding the use of multiple endoscopic, radiologic and functional gastrointestinal tests, WMC can provide 
new diagnoses, leads to a change in management decision and help to direct further focused work-ups in 
patients with suspected disordered motility. (1) However, while WMC is comparable to other modalities in 
use for detecting delayed gastric emptying and slow-transit constipation, data are insufficient to determine the 
optimal timing of WMC in diagnostic algorithms. (2) SmartPill as proposed for Appellant does not meet 
Medicare coverage criteria for medically 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 SmartPill Motility Study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve SmartPill Motility Study (91112).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 29, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on April 29, 2021.
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 and can take part in intense rehabilitation 
to recover as quickly and fully as possible. The Plan denied your request. The Plan says an intensive 
rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrode array 
(64650) implantable neurostimulator electrode (L8680). 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that you are requesting review for medical 
necessity for the procedure and equipment listed. The facility will bill for the equipment to be used for this 
procedure. The Plan denied your request. The Plan says that this request is not medically necessary because the 
records show the enrollee has not exhausted other methods of pain control. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 spinal cord stimulator. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has failed back surgery syndrome. She currently takes Diclofenac, 
Gabapentin, Flexeril, and Cymbalta for pain. She uses a TENS unit and heat/ice for pain relief. She has had 
Epidural Steroid injections as well as SI joint injections. She had physical therapy in the past and has had a 
psychiatric evaluation. The enrollee meets the NCD and LCD criteria for a spinal cord stimulator trial. The 
request is medically reasonable and 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 spinal cord stimulator have been met. Therefore, we decided that the Plan has to 
pre-approve percutaneous implantation of neurostimulator electrode array (64650) implantable neurostimulator 
electrode (L8680).  
 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.