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

 
We decided that the Plan does not have to pay for procedure codes 37233 and 37253 provided to the enrollee 
on September 30, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 37233: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to 
code for primary procedure) 
 
 CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 37233 codes for 
atherectomy of an additional tibial vessel after the initial. The code for posterior tibial artery atherectomy was 
already approved and covered. Treatment of the tibial peroneal trunk is considered a component of the 
posterior tibial artery treatment and is not separately billable. In terms of CPT 37253, this codes for 
performance of intravascular ultrasound (IVUS) of additional vessels after the initial - this code includes 
supervision and interpretation of the findings. Documentation of IVUS findings is sparse and is insufficient to 
justify additional IVUS codes beyond what was already covered. 
 
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 procedure codes 37233 and 37253 provided to the enrollee on September 30, 2022.
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 an IRF admission is medically necessary. 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 the enrollee does 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from August 21, 2021, 
to August 31, 2021. 
 
You asked the Plan to pay for SNF care. You say that these services were necessary and reported correctly. The 
Plan denied your request. The Plan says that this claim is a duplicate of a previous claim which has already 
been considered for payment. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. The rules 
also 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. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, there is no evidence to show that a claim 
for SNF care provided to the enrollee for the dates in question has been paid. The Plan has provided no other 
reason for denial, and the original claim shows a valid rate code for SNF care. Based on this information, we 
decided that Medicare rules for coverage of SNF care have been met. Therefore, we decided that the Plan has 
to pay for skilled nursing facility (SNF) services provided from August 21, 2021, to August 31, 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 transfer to the LTACH is not medically necessary as the patient is not yet stable for 
transfer and as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended.  
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission for an electroencephalogram 
with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; 
with intermittent monitoring and maintenance (95715). 
 
 
 
 You asked the Plan to pre-approve inpatient admission for a VEEG. You say that monitoring for localization of 
cerebral seizure focuses by cable or radio, 16 or more channel telemetry, combined electroencephalographic 
and video recording and interpretation is medically necessary for the enrollee's medical condition. The Plan 
denied your request. The Plan says the requested services do not meet the rules for approval. The enrollee does 
not have more complex than expected surgery/procedure nor does he have any periprocedural or post procedure 
complication which need inpatient care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollees 
condition can be managed safely only in the inpatient hospital setting.  
 
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 inpatient admission for a VEEG. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee was 
recently diagnosed with potential seizure disorder. After further review on April 4, 2022, after the enrollee had 
his wisdom teeth pulled, the enrollees potential disorder was more convincing due to a focal unaware seizure.  
There is no documentation provided indicating medical necessity for inpatient level of care services for the 
requested procedure. The review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission for a VEEG have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient admission for an electroencephalogram with video (VEEG), 
review of data, technical description by EEG technologist, each increment of 12-26 hours; with intermittent 
monitoring and maintenance (95715).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional levels for a facet joint injection provided to 
the enrollee on August 17, 2022. 
 
You asked the Plan to pre-approve the services. You say that the documentation supports medical necessity. 
The Plan denied your request. The Plan says the provider did not send evidence of a unique circumstance to 
indicate additional levels. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that the records do not support a need for additional levels for the facet 
joint injections. There are not any unique circumstances that would necessitate the additional levels.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional levels for a facet joint injection provided to the enrollee on August 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 19318-LT and 19318-RT billed for date of 
service March 2, 2022. 
 
You asked the Plan to pay for procedure codes 19318-LT and 19318-RT. You say that you disagree with the 
denial. 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 codes 19318-LT and 19318-RT is 1. The MAI value for this code is 2. You 
billed 2 units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 19318-LT and 19318-RT have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 19318-LT and 19318-RT billed for date of service March 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) procedure of the 
lumbar spinal canal and contents without using contrast material (CPT 72148). 
 
You asked the Plan to pre-approve an MRI. You say that the requested MRI is medically necessary. The Plan 
denied your request. The Plan says the requested MRI does not meet the Medicare coverage guidelines. 
 
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 an MRI. Our reviewer says that the 
requested MRI is not medically necessary in this case. Our physician reviewer found that the records do not 
show adequate conservative measures to include physical therapy for back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) procedure of the lumbar spinal canal and contents without 
using contrast material (CPT 72148).
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 the enrollee is medically stable and will 
benefit to transfer to LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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 pay for a work related or medical disability examination provided on 
August 23, 2022. 
 
You asked the Plan to pay for the work related or medical disability examination. The Plan denied your 
request. The Plan says a work related or medical disability examination is considered a fitness-for-duty medical 
exam and is not an exam for preventive care. 
 
The Plan contract covers an annual routine preventive physical exam. The Plan says that non-Medicare covered 
routine physical exams are covered once every calendar year. This comprehensive physical must include a 
preventive medicine evaluation and management, including an age and gender appropriate history, 
examination, and counseling/anticipatory guidance/risk factor reduction interventions. 
 
We looked at the file and the Plans rules. The file shows the exam was for a work-related or medical disability 
examination purpose and is not an exam for preventive care. Therefore, we decided that the Plan does not have 
to pay for a work related or medical disability examination provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152 and 
99153) provided to the enrollee on March 31, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
CPT 99153: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation submitted did 
not indicate the presence of an independent trained observer during the procedure for the billed services. In 
addition, there were no anesthesiology records documenting intra-operative monitoring of this patient 
(including blood pressure, heart rate, respiratory rate, EKG, oxygen saturation) or medications administered. 
The reviewed has determined that the use of CPT 99152 and 99153 are not supported by the records provided. 
 
Additionally, Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE 
are not payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting.   
 
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 moderate sedation services (procedure code 99152 and 99153) provided to the enrollee on 
March 31, 2022.
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 the rehabilitation in order to be able to 
return to independent living. The Plan denied your request. The Plan says records show that there is no need for 
an intensive rehabilitation program. Home physical therapy or physical therapy at a skilled nursing facility may 
be covered if requested. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient physical therapy services rendered on 
December 7, 2021, to December 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not processed by the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that they have not received an Explanation of Benefits (EOB) from the primary insurance for this claim. As the 
secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied 
the claim for these services. Therefore, we decided that the Plan does not have to pay for the outpatient 
physical therapy services rendered on December 7, 2021, to December 30, 2021.