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

 
We decided that the Plan has to pay for the critical care, evaluation and management of the critically ill or 
critically injured patient; first 30-74 minutes (99291) provided on October 24, 2022. 
 
You asked the Plan to pay for the critical care. You say that the claim should be paid. The Plan denied your 
request. The Plan says that codes 94760, 94761, and 94762 are included in the critical care services listed in 
Group 2: Codes. The Plan states these codes will not be paid separately when billed with a critical care code. 
 
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 did not provide other codes that were billed. The only code we see 
billed is 99291. Reviewing the medical record shows that this service was performed for 37 minutes. Therefore, 
we decided that the Plan has to pay for the critical care, evaluation and management of the critically ill or 
critically injured patient; first 30-74 minutes (99291) provided on October 24, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexlansoprazole. 
 
You asked the Plan to pre-approve Dexlansoprazole. You say that the enrollee needs this drug. The Plan denied 
your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexlansoprazole.  
 
Benefits for Dexlansoprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services provided on August 6, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that this stay is denied. 
 
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 states that these services are not covered. No explanation or Medicare 
rules were provided to support this decision. The Plan did not substantiate their denial. Therefore, we decided 
that the Plan has to pay for the inpatient services provided on August 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair, powered pressure-reducing air 
mattress, and a heavy-duty walker. 
 
You asked the Plan to pre-approve the bath/shower chair, powered pressure-reducing air mattress, and a heavy-
duty walker. The Plan denied your request. The Plan says the bath/shower chair is not covered by Medicare. 
The Plan says the documentation provided does not show that you weigh more than 300 pounds, therefore 
criteria for the heavy-duty walker has not been met. The Plan also says the pressure support mattress is not 
covered as you do not have any documented wounds. 
 
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 powered pressure-reducing air 
mattress. Our reviewer says that the pressure support mattress is not medically necessary. Our physician 
reviewer found you are already using a pressure support mattress, but it is hurting your back. This is a request 
for E0277, a powered pressure-reducing air mattress. You do not meet local coverage determinations criteria as 
you don't have any documented wounds. 
 
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 pressure support mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the pressure-reducing air mattress. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. The heavy-duty walker does not meet criteria for coverage as the information 
provided does not demonstrate that you weigh more than 300 pounds.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair, powered pressure-
reducing air mattress, and a heavy-duty walker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical vision examination and evaluation with 
initiation of diagnostic and treatment program (92004) to be provided by tertiary provider. 
 
You asked the Plan to pre-approve outpatient service. You say that your vision has changed drastically within 
five weeks. You say that your doctor advised you could go blind. You also say that you would like to go to this 
provider because they treated your retina years ago. The Plan denied your request. The Plan says the enrollee 
does not require care with a highly specialized tertiary care provider. The Plan also says that the requested care 
can be provided in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 outpatient service. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the provided documentation indicates 
you were offered an appointment within two to three weeks (sooner if needed based on the condition) with a 
retina specialist. The reviewer found that the documentation does not indicate an acute or complex condition 
that requires referral to a tertiary level of care. Therefore, the reviewer found that the Plan has demonstrated 
that there is an available in-network provider that meets the standards of care required for treatment of your 
condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a medical vision examination and evaluation with initiation of diagnostic and treatment 
program (92004) to be provided by tertiary provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 
21, 2022, to October 25, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as you do not meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from October 21, 2022, to October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on September 24, 2022, and 
September 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
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 the services. Our reviewer says that the use of code 99233 is 
not supported by the records provided. Our reviewer found that the provided documentation for the requested 
dates shows only brief reports of no distress in the history sections and a very basic physical exam for each 
date, without evidence of a detailed history or physical. The enrollee was treated with Toradol, Tramadol, and 
Zofran for her pain, and no invasive treatment was given or planned on these dates. The enrollee was stable and 
there was no indication there was decision-making of high complexity shown in these two progress notes. 
 
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 the services (99233) provided on September 24, 2022, and September 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services (92014, 92134) provided on 
September 26, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ophthalmological services have not been met. Specifically, this claim has been billed with ICD-10 
code E08.3393 as the primary diagnosis code. E08.3393 has a code first note, meaning that the underlying condition must be sequenced first on the claim. Therefore, we decided that the Plan does not have to pay for 
ophthalmological services (92014, 92134) provided on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve implantable loop recorder. You say that the enrollee meets criteria for this. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that implantable loop recorders may be covered when 
syncope is thought to be cardiac-related but is too infrequent to be detected by a Holter monitor or traditional 
pre-symptom MLR. 
 
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 implantable loop recorder. Our 
reviewer says that the enrollee does not meet criteria for this procedure. Our physician reviewer found the 
enrollee has complaints of infrequent severe symptoms of palpitations accompanied by dizziness. The enrollee 
is reported to have a history of supraventricular tachycardia (SVT) with features suggestive of atrial 
tachycardia. The requesting physician notes that despite repeated non-invasive monitors, they have not been 
able to capture one of these episodes to document the arrhythmia. The provider feels that the next best 
diagnostic step is implantation of a loop recorder for definitive arrhythmia/symptom correlation. There is no documentation of syncope thought to be of cardiac origin; and there is no documentation of cryptogenic stroke. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
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 a semi-electric hospital bed. You say that you are currently sleeping on the 
couch in a reclining chair. You also say that you need this hospital bed for the rest of your life. The Plan denied 
your request. The Plan says the requested semi-electric bed is 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 a semi-electric hospital bed. Our 
reviewer says that a semi-electric hospital bed is not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that the enrollee has significantly impaired motor strength. There is 
insufficient clinical history regarding the enrollees level of mobility, specifically with regards to performing 
transfers, bed mobility and ambulation. There is no history of skin breakdown, pressure wounds or a need to be 
re-positioned for pressure relief while in bed. The reviewer found that it is unclear why the enrollee would need 
a semi-electric hospital bed with mattress and rails. Therefore, the reviewer found that the requested semi-
electric hospital bed with mattress and rails is not 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 a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service July 16, 
2022. 
 You asked the Plan to pay for procedure code 99292. You say that this service was necessary and was reported 
correctly. The Plan denied your request. The Plan says payment for code 99292 is bundled into payment for 
code 36556. 
 
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, we have confirmed that code 99292 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99292 billed for date of service July 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided from November 18, 2022, to 
November 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded". 
 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 use of code 99233 is 
not supported by the records provided. Our reviewer found that the billed evaluation and management code 
requires a medically appropriate history and/or examination and high level of medical decision making. In this 
case, the medical records submitted did not support a detailed interval history or medical decision making of 
high complexity for November 18, 2022, November 19, 2022, and November 20, 2022. 
 
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 the services (99233) provided from November 18, 2022, to November 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical facet radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve a cervical facet 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 an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 cervical facet RFA. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the request is not medically 
necessary because the records do not show evidence of at least 80% relief of pain from two (2) sets of MBBs. 
The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 cervical facet RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cervical facet radiofrequency ablation (RFA).
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 had a leg amputation and needs to learn 
to walk again before returning home. The Plan denied your request. The Plan says the enrollee's care can be 
provided 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 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.