Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0428-HH, A0425-HH) 
provided on July 20, 2022. 
 
You asked the Plan to pay for transportation services. You say that this was transportation provided after 
hospital discharge and should be paid. The Plan denied your request. The Plan says the enrollee maintained 
inpatient status at one hospital from July 14, 2022, to July 28, 2022. Transportation provided on July 20, 2022, 
would fall under inpatient transportation and is included in the rate paid to the hospital. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the 
beneficiary maintains inpatient status with the original provider. This movement of the patient is considered patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of transportation services have not been met. Specifically, the record shows that the enrollee 
maintained inpatient status at one facility throughout the date in question. This means that the services at issue 
are considered patient transportation and paid to the facility. Therefore, we decided that the Plan does not have 
to pay for ambulance transportation services (A0428-HH, A0425-HH) provided on July 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF services requested 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63012 and 22612 billed for date of service 
March 14, 2022. 
 
You asked the Plan to pay for procedure codes 63012 and 22612. The Plan denied your request. The Plan says 
payment for codes 63012 and 22612 is bundled into payment for code 63047.  
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 63012 
is a column II code to column I code 63047. We have also confirmed that code 22612 is a column II code to 
column I code 22633. 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 codes 63012 and 22612 billed for date of service March 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity, without contrast material(s) (73718), MRI of the lower extremity other than joint, with contrast 
material(s) (73719), MRI of the lower extremity other than joint; without contrast material(s), followed by 
contrast material(s) and further sequences (73720), MRI of any joint of lower extremity; without contrast 
material (73721), MRI of any joint of lower extremity, with contrast material(s) (73722), and an MRI of any 
joint of lower extremity, without contrast material(s) (73723). 
 
You asked the Plan to pre-approve the MRIs. You say that a new MRI is required because the previous MRI is 
5 years old and is not adequate to make decisions about additional conservative care versus surgical referral. 
The Plan denied your request. The Plan says based on the provided information, these MRIs are 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 the MRIs. Our physician reviewer 
found you already have a diagnosis from the plain x-rays. Our reviewer also found that this request is not 
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 the MRIs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower extremity, without contrast material(s) 
(73718), MRI of the lower extremity other than joint, with contrast material(s) (73719), MRI of the lower 
extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences 
(73720), MRI of any joint of lower extremity; without contrast material (73721), MRI of any joint of lower 
extremity, with contrast material(s) (73722), and an MRI of any joint of lower extremity, without contrast 
material(s) (73723).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 9930 billed for date of service April 15, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the units of 
service exceed the MUE value. 
 
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 looked at the file and the rules. The claim information shows that CPT code 99310 was billed with 1 unit of 
service. Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we 
decided that the Plan has to pay for procedure code 9930 billed for date of service April 15, 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 pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided July 18, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided July 
18, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says a trial 
period has been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that electrical nerve stimulators are only covered 
under certain medical indications.  
 
 
 We looked at the file and Medicare rules. The file shows that the Plan has agreed to pre-approve a 14-day trial 
period for the requested stimulator. Permanent implantation may be approved if there is demonstration of pain 
relief with the approved temporary implantation. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a nerve 
stimulation services beyond the approved temporary implantation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4649 billed for date of service April 29, 2022. 
 
You asked the Plan to pay for code A4649. The Plan denied your request. The Plan says code A4649 is 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4649 has a status indicator of P on the Physician Fee Schedule. This means that code A4649 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code A4649 have not been met. Therefore, we decided that the Plan does not have to pay for code A4649 
billed for date of service April 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor.. You say that this sensor is medically 
necessary. The Plan denied your request. The Plan says a continuous glucose monitor is not medically 
necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a continuous glucose monitor. Our 
reviewer says that the requested item is not medically necessary. Our physician reviewer found the medical 
records do not document the beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary. 
 
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 continuous glucose monitor. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has rehabilitation needs to improve 
strength, endurance, activities of daily living, and mobility as well as medical needs that necessitate daily 
medical oversight. You say that the enrollee is motivated to improve and will tolerate the three hours of therapy 
required of acute rehabilitation. The Plan denied your request. The Plan says the IRF admission is denied due 
to coverage not being met and 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 the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
October 5, 2022. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
 We find that CPT code 99223 is not supported in the medical record. Specifically, review of the claims history, 
an outpatient claim was billed for the same date of service. This means this claim is not payable as billed. 
Based on this information, we decided that Medicare rules for coverage of the initial hospital care services have 
not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services 
coded 99223 provided on October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 7, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0427-HH, A0425-HH) 
provided on April 30, 2022. 
 
You asked the Plan to pay for ambulance transportation. You say that this was emergency and medically 
necessary transport which should be covered. The Plan denied your request. The Plan says the enrollee was 
admitted to one facility and maintained inpatient status from April 16, 2022, to May 20, 2022. This means that 
this transport is considered "patient transportation" and is included in the payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the 
beneficiary maintains inpatient status with the original provider. This movement of the patient is considered patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of transportation services have not been met. Specifically, the record shows that the enrollee 
maintained inpatient status at one facility throughout the date in question. This means that the services at issue 
are considered patient transportation and are paid to the facility. Therefore, we decided that the Plan does not 
have to pay for ambulance transportation services (A0427-HH, A0425-HH) provided on April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 27, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that medical records were provided. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service June 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve injection (64454). 
 
You asked the Plan to pre-approve a genicular nerve injection. The Plan denied your request. The Plan says 
there is not enough medical evidence that shows the procedure is helpful and safe for knee pain. 
 
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 genicular nerve injection. Our 
reviewer says that a genicular nerve injection is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee a history of bilateral knee pain due to osteoarthritis. They have been 
treated with medical therapy and corticosteroid injections, and bilateral genicular nerve blocks have been 
recommended. Our reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablations 
are considered investigational and not medically necessary for the treatment of chronic knee pain, including 
osteoarthritis of the knee. Our physician reviewer also found that the genicular nerve blocks are considered 
experimental/investigational in nature. 
 
 
 
 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 genicular nerve injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve injection (64454).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77065 billed for date of service September 
14, 2022. 
 
You asked the Plan to pay for procedure code 77065. You say that the service at issue has been billed correctly. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 77065 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77065 billed for date of service September 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that the admission to 
a SNF is not medically necessary. 
 
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 pre-approve 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 that there is no documentation that daily skilled services are required. Although the 
records document you are very limited functionally, the provided records do not document a significant decline 
in your functional status compared to your recent baseline to necessitate daily inpatient skilled therapy services. 
The records support those services in the home or an assisted living facility with home health care or in a long-
term care facility on a part time basis are appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.