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

 
We decided that the Plan does not have to pay for code 99220 billed for date of service October 13, 2022. 
 
You asked the Plan to pay for code 99220. You say that medical records have been provided to support 
payment of this code. The Plan denied your request. The Plan says code 99220 is not supported in the medical 
record. The records do not support a comprehensive history and decision making of high complexity. 
 
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 99220 is initial observation 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. 
 
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 code 99220. Our reviewer says that code 99220 is not supported in the medical record. Our reviewer found the enrollee was a then 84-year-old male with a history of 
benign prostatic hypertrophy with indwelling Foley catheter, osteoarthritis of the knee, and status post 
pacemaker who presented to the emergency room with weakness and a urinary tract infection. He was 
evaluated, started on IV antibiotics and admitted. Procedure code 99220 was not supported because there was 
no comprehensive history or 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 code 99220 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99220 billed for date of service October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided at an out-of-network 
(OON) facility. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the necessary 
services may be obtained in-network. 
 
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 facility in this case is not a network provider with the Plan. The Plan has network facilities 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
surgery services to be provided at an out-of-network (OON) facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on March 17, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that this claim should not be denying 
against the inpatient claim. The Plan denied your request. The Plan says this claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that all outpatient services provided with three days 
prior to an inpatient admission, including the date of admission, must be included in the inpatient admission 
claim. 
 
 
 We looked at the file and Medicare rules. The record shows that the enrollee was admitted as an inpatient on 
March 20, 2022, and this March 17, 2022, date of service at appeal is within three days of the inpatient 
admission. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital 
services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital 
services provided on March 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on May 20, 2021, billed with 
codes 95955-26-XU, 95885-26 x2, 95887-26-XS, 95937-26 and 95907-26. 
 
You asked the Plan to pay for the imaging services provided. 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 codes 
 
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 codes 95955-26-XU, 95885-26 x2, 95887-26-XS, 95937-26 
and 95907-26 are Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery), Needle 
electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, 
amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure), 
Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure), 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method, and Nerve 
conduction studies; 1-2 studies. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed codes Our reviewer found the procedure codes billed were not 
supported by the documentation provided. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on May 20, 2021, billed with codes 95955-26-XU, 
95885-26 x2, 95887-26-XS, 95937-26 and 95907-26.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the enrollee has not 
been evaluated by an endocrinologist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Evenity. Our physician reviewer found 
that the enrollee has age-related osteoporosis. The records do not reveal the enrollee having consulted with an 
endocrinologist. Nor do the records show trial and failure of first- and second-line medication and lifestyle 
treatment options to improve her condition prior to considering this newer medication. Therefore, based on the 
provided documentation, Evenity is not medically reasonable and necessary for this enrollee, and it is not clear 
if it would be safe or effective for this enrollee. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
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 member meets Medicare criteria for and will 
benefit from an IRF admission. The Plan denied your request. The Plan says the member does not meet the 
Medicare criteria for an IRF admission. 
 
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 member continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement; however, the documentation doesnt support that the 
member meets the criteria for admission to an acute inpatient rehabilitation facility. There is no indication that 
the member would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a 
week, under the supervision of a physician with at least 3 visits weekly to regain or maintain functional status. 
The member can receive further services at 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of any joint of the upper extremity. 
 
You asked the Plan to pre-approve an MRI of any joint of the upper extremity. You say that the enrollee would 
like reconsideration because the services are medically necessary. The Plan denied your request. The Plan says 
an MRI of any joint of the upper extremity is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI of any joint of the upper 
extremity. Our reviewer says that the requested MRI of any joint of the upper extremity is not medically 
necessary. Our physician reviewer found the enrollee has decreased right arm strength and decreased range of 
motion but no red flag. Although x-rays have been ordered there were not results in the records. There was no 
specific right shoulder challenge testing done during the last encounter and no physical therapy being 
attempted. Per the guidelines, a 6-week course of supervised physical therapy is necessary prior to receiving an 
MRI without red flags. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of any joint of the upper extremity have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an MRI of any joint of the upper extremity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is the device that will 
work with the enrollee. The Plan denied your request. The Plan says the enrollee has not completed a 4-week 
trial with a basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient suffers from chronic respiratory 
failure secondary to chronic obstructive pulmonary disease (COPD). She is not capable of being adequately 
supported by bilevel positive airway (BiPAP) therapy. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for this patient. The patient's condition can be managed with a BiPAP 
device with average volume-assured pressure support (AVAPS) technology. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease.  The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability.  The plan has 
indicated coverage for such a device is available upon request. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 are unable to be independent and require 
frequent physical/occupational therapy services. The Plan denied your request. The Plan says the IRF services 
you are requesting do not meet the requirements for approval. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
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 special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that this benefit was supposed to be approved from 
January 20, 2023, to July 19, 2023. You say that you have an approval code for the SSBCI benefit. You also 
say that you will go to the emergency room if that is what it takes for this benefit to be approved. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary 
because alternative devices cannot provide the essential multiple ventilation setting that with assist in the 
patient being able to complete their activities of daily living. The Plan denied your request. The Plan says the 
patient's condition can be managed with bi-level positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability.  The plan has 
indicated coverage for such a device is available upon request. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 need extensive therapy while 
continuing to receive acute care in the LTACH setting. The Plan denied your request. The Plan says you can 
stay in the hospital until you are safe for transfer or discharge. 
 
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 there is no evidence that you require services that are not currently available. There is 
no advantage in transferring to an LTACH. You can remain at the current acute care hospital until such time no 
acute services are required. You can then be transferred or discharged to a lower level of care for any ongoing 
long term care needs. 
 
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 pre-approve implantation of a cardiac contractility modulation 
system in the form of the Optimizer Smart device (CCM). 
 
You asked the Plan to pre-approve implantation of a cardiac contractility modulation system in the form of the 
Optimizer Smart device (CCM). You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the requested services are 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 implantation of a cardiac contractility 
modulation system in the form of the Optimizer Smart device (CCM). Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has left ventricular dysfunction and continued symptoms, despite medical treatment, thought to reflect congestive heart failure. An exhaustive review of the current medical literature pertaining to the CCM 
system confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized 
clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from 
multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective 
functional capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject of 
multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to 
quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume 
clinical outcomes and benefit. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a cardiac contractility modulation system in the form of the 
Optimizer Smart device (CCM) have not been met. Therefore, we decided that the Plan does not have to pre-
approve implantation of a cardiac contractility modulation system in the form of the Optimizer Smart device 
(CCM).