Persius/hicric huggingface dataset:
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have not been met. 
 
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 has ongoing acute medical issues and still requires acute care services 
before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that they are not 
currently receiving but that would be available at the LTACH facility. 
 
 
 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: 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. The Plan denied your request. The Plan says the enrollee has no 
functional improvements from physical therapy and no medical instabilities. 
 
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. 
 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: 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's admission to a Long-Term 
Acute Care Facility is needed. The Plan denied your request. The Plan says the enrollee's records do not show 
the need for continued treatments and care that can only be given in a hospital setting, continued care needs 
include wound care, intravenous antibiotics, and physical therapy, when ready to leave the hospital, services 
can safely be provided in another setting, a Skilled Nursing Facility. 
 
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 are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. 
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day continuous glucose monitor 
(CGM) reader device (E2103). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM device. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 
CGM device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14 Day continuous glucose monitor (CGM) reader device (E2103).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nonadjunctive, nonimplanted continuous glucose 
monitor (CGM) or receiver (E2103) and a supply allowance for nonadjunctive, nonimplanted continuous 
glucose monitor (CGM), includes all supplies and accessories (A4239). 
 
 
 
 
 You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee checks her glucose a lot 
every day due to high and low levels of glucose and having to get insulin adjustments. Not having this 
equipment can seriously jeopardize the enrollees ability to regain maximum function. The Plan denied your 
request. The Plan says the records show the enrollee has type 2 diabetes and is being treated with insulin 
injections twice daily. Medicare guidelines show that the enrollee must be insulin-treated with multiple (three 
or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump. The 
enrollee does not meet approval for the requested CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
nonadjunctive, nonimplanted continuous glucose monitor (CGM) or receiver (E2103) and a supply allowance 
for nonadjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories 
(A4239).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has been in and out of the hospital. 
They have wounds that require daily dressings and need assistance with daily living activities. The Plan denied 
your request. The Plan says the request 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 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 have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 a continuation of SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device (K1018, K1019x3) 
at the in-network benefit level by an out of network provider. 
 
You asked the Plan to pre-approve Cala Trio nerve stimulator device. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the requested items are not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We looked at the file and Medicare rules. Medicare rules say where electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary. Based on this information, 
we decided that Medicare rules for coverage of Cala Trio nerve stimulator device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device (K1018, 
K1019x3) at the in-network benefit level by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopic rotator cuff repair (29827), decompression 
(29826), and distal claviculectomy (Mumford procedure) (29824). 
 
You asked the Plan to pre-approve arthroscopic rotator cuff repair, decompression, and distal claviculectomy 
(Mumford procedure). You say that the services are necessary. The Plan denied your request. The Plan says 
medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 arthroscopic rotator cuff repair, 
decompression, and distal claviculectomy (Mumford procedure). Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested arthroscopic rotator cuff repair, 
decompression, and distal claviculectomy (Mumford procedure), in this case, is not medically reasonable or 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 arthroscopic rotator cuff repair, decompression, and distal claviculectomy 
(Mumford procedure) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
arthroscopic rotator cuff repair (29827), decompression (29826), and distal claviculectomy (Mumford 
procedure) (29824).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for codes 99285 and 99053 provided on April 10, 2021. 
 
You asked the Plan to pay for codes 99285 and 99053. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
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. 
 
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. The medical records submitted show that two separate 
services at different times were provided on the same date of service. Based on this information, we decided 
that Medicare rules for coverage of codes 99285 and 99053 have been met. Therefore, we decided that the Plan 
has to pay for codes 99285 and 99053 provided on April 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a scooter. You say that the enrollee prefers to use you as their supplier for 
the requested scooter. You also say you are willing to take the Plan's fee schedule. The Plan denied your 
request. The Plan says the enrollee must use network providers to get medical care and services. The Plan also 
says they have confirmed that the requested scooter may be obtained by an in-network supplier. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800) to 
be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99214 provided on November 15, 
2022. 
 
You asked the Plan to pay for the office visit. 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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 We find that CPT code 99214 is not supported in the medical record. Specifically, code 99214 was billed on 
the same date of service as surgery procedure 20600 (Arthrocentesis, aspiration and/or injection, small joint or 
bursa (eg, fingers, toes); without ultrasound guidance). Since 99214 was not billed with an appropriate 
modifier, this code is considered included in the global surgery period of code 20600. This means code 99214 
is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 
99214 provided on November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the naso- or oro-gastric tube placement services coded 43752 
provided on July 25, 2022. 
 
You asked the Plan to pay for the naso- or oro-gastric tube placement services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed 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 43752 is naso- or oro-gastric tube placement, requiring 
physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report). 
 
We find that CPT code 43752 is not supported in the medical record. Specifically, the medical records indicate 
that insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contracts injection(s), 
image documentation and report was performed. There is a more appropriate code to be billed for the services 
provided. Based on this information, we decided that Medicare rules for coverage of the naso- or oro-gastric 
tube placement services have not been met. Therefore, we decided that the Plan does not have to pay for the 
naso- or oro-gastric tube placement services coded 43752 provided on July 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 duplex scan of extremity veins 
including responses to compression and other maneuvers; unilateral or limited study provided on July 12, 2022. 
 
You asked the Plan to pay for duplex scan of extremity veins. You say that the claim should be paid as billed. 
The Plan denied your request. The Plan says some of the billed services were approved on the appeal; however, 
procedure code 93971 remains unsupported. 
 
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 93971 is duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study. 
 
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 duplex scan of extremity veins. Our reviewer says that the 
documentation does not support that the services described by these codes were performed. Our reviewer found the procedure report does not provide clear documentation to support the duplex scan of extremity veins billed 
were provided to support reporting 93971. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of duplex scan of extremity veins have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 93971 duplex scan of extremity veins including responses to 
compression and other maneuvers; unilateral or limited study provided on July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87634, 87632 and 87503 billed for date of 
service February 24, 2022. 
 
You asked the Plan to pay for procedure codes 87634, 87632 and 87503. You say that these services were 
necessary and appropriate. The Plan denied your request. The Plan says payment for code 87634 is bundled 
into payment for code 87632. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that respiratory pathogen 
panels with more than 5 respiratory pathogens performed in the Part B outpatient setting are considered not 
medically reasonable and necessary. 
 
In this case, we have confirmed that code 87634 is a column II code to column I code 87632. This claim has 
not been billed with an appropriate modifier to bypass the edit. In addition, codes 87503 and 87632 report 
respiratory pathogen panel testing in excess of 5 pathogens. Therefore, these services are not considered 
medically necessary in this case. 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 87634, 87632 and 87503 billed 
for date of service February 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 66991 billed for date of service September 
27, 2022. 
 
You asked the Plan to pay for procedure code 66991. 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 code 66991 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 66991 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 66991 billed for date of service September 27, 2022.