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

 
We decided that the Plan does not have to pay for the vascular surgery services provided on November 18, 
2022, billed with codes 37233 and 37253. 
 
You asked the Plan to pay for the services as billed. You say that this is billed correctly and should be paid. 
The Plan denied your request. The Plan says the 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 37233 is 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). The 
definition of 37253 is 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 as billed. Our reviewer says that the codes at 
issue are not supported by the records. Our reviewer found in regard to codes 37233 and 37253, the operative 
report describes a procedure performed in the left posterior tibial artery and left tibial peroneal trunk. The 
tibioperoneal trunk is considered part of any distal intervention in the posterior tibial or peroneal 
artery. Therefore, this service denied correctly. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the vascular surgery services provided on November 18, 2022, billed with codes 
37233 and 37253.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on June 
6, 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 Current Procedural Terminology (CPT) code 99223-57 (1 unit) remains 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 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 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 enrollee presented to the 
hospital with left hip pain. The imaging showed intertrochanteric femur fracture. The examination was focused 
on the extremities. Options for surgery vs nonsurgical options were discussed and surgery correction was 
decided on. The provided note from 6/6/2022 did not include evidence of a comprehensive history or physical 
and did not show evidence of medical decision making of high complexity to justify the code. 
 
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 initial hospital care (procedure code 99223) rendered on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 81335) rendered on June 
22, 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 this is not covered. 
 
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 81335 is "TPMT (thiopurine S-methyltransferase) (eg, 
drug metabolism), gene analysis, common variants (eg, *2, *3)." 
 
We find that CPT code 81335 is not supported in the medical record. Specifically, this code has a status 
indicator X, which means it is excluded from coverage. 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 laboratory services (procedure code 81335) rendered on June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilateral leg sclerotherapy (36471). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee did not meet 
the coverage criteria for the requested service. 
 
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 outpatient procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found for bilateral leg sclerotherapy to be considered medically necessary there would need 
to be evidence that truncal (saphenous) reflux is not present and that the enrollee has continued symptoms 
despite conservative efforts for at least 6 weeks following correction of saphenous reflux.  Additionally, to be 
considered medically necessary, the veins in question need to be demonstrated as greater than 4 mm in 
diameter. The documentation does not meet coverage criteria and does not support the medical necessity of the 
treatments in question. 
 
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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the bilateral leg sclerotherapy (36471).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the right sacroiliac joint (SIJ) fusion (27279). 
 
You asked the Plan to pre-approve the right sacroiliac joint (SIJ) fusion. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is 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 the right sacroiliac joint (SIJ) fusion. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are no imaging studies showing SI joint instability, lesion, or fracture. 
SIJ fusion for degenerative back pain is experimental. 
 
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 right sacroiliac joint (SIJ) fusion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the right sacroiliac joint (SIJ) fusion (27279).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this is 
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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the magnetic resonance imaging (MRI) shows facet degenerative joint disease 
(DJD) and disc bulging. As such, the Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not at a functional baseline and 
requires aggressive therapy to regain function lost by recent hospitalizations. The Plan denied your request. The 
Plan says the enrollee's current needs can be managed at a lower level of care, such as long-term care with 
Medicare Part B therapy services to support their goals. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on November 3, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 emergency room services. Our reviewer says that the 
records provided do not support the code billed. Our reviewer found the documentation does not include a 
comprehensive history or high-complexity medical decision making. 
 
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 emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99285) provided on November 3, 2022.
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 disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested device 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 the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found the enrollee is status post revision of a right-sided total knee 
arthroplasty. The documentation doesnt support that the member has a condition that requires frequent 
positioning of the bed and mattress to alleviate pain, promote good body alignment, prevent contractures or 
avoid respiratory infections in a way that an ordinary bed is not able to. Therefore, the enrollee does not meet 
criteria for the requested device. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve implantation of a CardioMEMS device. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 CardioMEMS device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there remains a dearth of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
 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 CardioMEMS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of a CardioMEMS device (33289).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled care can be provided in an alternative setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for you. Our physician reviewer found 
that you have complex functional impairments and active medical comorbidities. The complexity of your 
documented nursing, medical and rehabilitation needs would be expected to require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. IRF criteria is met. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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 the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the documentation 
available for review does not indicate the member meets criteria for a home ventilator. There is no 
documentation of arterial blood gases, and the most pertinent information shows he has not used his continuous 
positive airway pressure (CPAP) device regularly. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 very heavy-duty power scooter (K0808). 
 
You asked the Plan to pre-approve the power scooter. You say that you do not want it for in your house. You 
want it to where you can get out and do some things. You do not want to sit in your house and die. You can 
only walk so far then get tired. The Plan denied your request. The Plan says the scooter has added capabilities 
that are not needed for use in the home and the scooter is being requested for use outside of the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation reveals that the enrollee has a mobility deficit, but the 
documentation does not reveal that it impairs MRADLs in the home and is unable to be alleviated by a walker 
in the home. The enrollee's appeal on February 23, 2023, states that the enrollee does not want the power 
wheelchair for the home but to go out and do things. The documentation does not support that the requested 
power scooter will significantly improve MRADL participation in the home. The Group 2 very heavy-duty 
power scooter K0808 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 the power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 very heavy-duty power scooter (K0808).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction. 
 
You asked the Plan to pre-approve the dental services. 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. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services do not 
have sufficient supporting documentation for them to be approved. Therefore, we decided that the Plan does 
not have to pre-approve a surgical extraction.