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

 
We decided that the Plan does not have to pay for code 99213 billed for date of service August 2, 2022. 
 
You asked the Plan to pay for code 99213. You say that this service was separately identifiable from 11900. 
The Plan denied your request. The Plan says this code is not separately payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a procedure has a global period of 000 or 010 
days, it is defined as a minor surgical procedure. In general, evaluation and management (E&M) services on 
the same date of service as the minor surgical procedure are included in the payment for the procedure. 
However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor 
surgical procedure is separately reportable with modifier 25. 
 
In this case, you billed code 11900 on the same date as the E&M service in dispute.  Code 11900 is a minor 
procedure. Although you indicated in your appeal that you appended a 25 modifier to the E&M code in dispute, 
the claim shows that no such modifier was billed.  Because no modifier was billed, there is no evidence that 
this service is separately reportable. You may contact the Plan directly for options for submitting a corrected 
claim. Based on this information, we decided that Medicare rules for coverage of code 99213 have not been met. Therefore, we decided that the Plan does not have to pay for code 99213 billed for date of service August 
2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from June 16, 2021, to 
June 18, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says you submitted supporting documentation for 
reconsideration of the DRG adjustment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 853. 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 pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee had complicated pyelonephritis. While the enrollee had pain, a low-grade fever and 
leukocytosis, these symptoms are consistent with his diagnosis. There is no evidence that the enrollee had 
systemic spread of his kidney infection or other organ failure due to his kidney infection. As such, the 
diagnoses of sepsis (A41.9) is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from June 16, 2021, to June 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields (G6001). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that it appears that the request is for 
daily image-guided radiation therapy (IGRT). IGRT is a means to improve set-up accuracy. IGRT uses daily 
image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows 
accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and 
thus allow reduction in the volume of normal tissues exposed to radiation. When treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. Using ultrasound on a daily basis is not 
unreasonable to offer but not necessary.  
 The device itself is Food and Drug Administration (FDA) approved for use with ultrasound though that in and 
of itself does not mean that daily imaging is necessary but simply that the device was designed to incorporate 
this functionality. Therefore to bill for daily simple simulations and/or image-guided radiation therapy (IGRT) 
for a technology for which need has not been established by published data or supported by consensus 
guidelines is not necessary. The billing for daily IGRT would not be furnished in accordance with accepted 
standards of medical practice.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasonic guidance for placement of radiation therapy fields (G6001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage of a home ventilator (E0466). 
 
You asked the Plan to pre-approve continued coverage of a home ventilator. You say that you have breathing 
problems at night from too much carbon monoxide. Going longer than needed for your machine coverage can 
kill you. The Plan denied your request. The Plan says the request for continued coverage of a home mechanical 
ventilator that is not being used by you is not covered. There is documentation to suggest that you are not using 
the 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 continued coverage of a home 
ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found you 
have a diagnosis of COPD, severe obesity, and obstructive sleep apnea. You have had a home ventilator since 
October 2021. Device download covering October 8 through January 10, 2023, shows you have used the device 
for at least 4 hours per night for 0% of nights. You are not using the device at all most nights. There is no 
documentation of chronic CO2 retention. You are not using the device enough for it to be effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued coverage of a home ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued coverage of a home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
14, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that these services were reasonable and 
appropriate. 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 99291 is 1. The MAI value for this code is 2. You billed 2 separate units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service September 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 21,2021 billed with 
codes 74230 and 74240. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid The Plan denied your request. The Plan says this is a noncovered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of imaging services provided have not been met. The procedure is a barium swallow study, and this means that it involves the administration of a substance to the enrollee. Therefore, we decided that the Plan 
does not have to pay for imaging services provided on December 21,2021 billed with codes 74230 and 74240.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee's health is in danger and can fail 
even worse without a ventilator. The Plan denied your request. The Plan says the request for a non-invasive 
ventilator (NIV) is not medically necessary because the documentation does not support that this device meets 
but does not exceed the enrollee's need. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) 
mode with auto-titration (AE) which could be provided by a BiPAP device with average volume assured 
pressure support (AVAPS) and a back-up rate.  As stated in the Local Coverage Determination (L33800): 
"Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD 
policy will be denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 needs services from an 
LTACH that cannot be rendered at a lower level of care. The Plan denied your request. The Plan says the 
records do not show that the enrollee needs continued treatments and care that can only be given in a hospital 
setting. 
 
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 she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 enrollees nursing, medical and rehabilitation needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee can receive further services at a lower 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 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 an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the medical records provided 
support the need for the requested services. The Plan denied your request. The Plan says the implantable loop 
recorder 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 an implantable loop recorder. Our 
reviewer says that an implantable loop recorder is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of atrial fibrillation for which she is 
anticoagulated. There is no documentation provided to suggest a history of unexplained syncope or any other 
apparent indication for an implantable loop recorder. There is insufficient documentation to support the 
medical necessity for insertion of an implantable loop recorder in this enrollee's clinical 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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for stem cells harvested for stem cell injection therapy, Native 
Stem Cell (38232, 38215, 38241), provided on September 23, 2021. 
 
You asked the Plan to pay for the stem cell harvesting/injection. 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 pay for the stem cell harvesting/injection. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation did not describe failure of conservative and standard 
treatments for the patient's condition. Also, stem cell therapy for knee conditions have not been FDA approved 
as of the date of this procedure due to lack of sufficient high-quality evidence to support its use over standard 
treatments. 
 
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 stem cell harvesting/injection have not been met. Therefore, we decided that 
the Plan does not have to pay for stem cells harvested for stem cell injection therapy, Native Stem Cell (38232, 
38215, 38241), provided on September 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 30, 2022, billed with 
codes 99291, 31500, and 93010. 
 
You asked the Plan to pay for the services as billed. You say that the records show that the services rendered 
were medically appropriate. The Plan denied your request. The Plan says the claim was not billed with an 
appropriate primary diagnosis code.  
The Plan must follow Medicare rules. Medicare rules say that providers must comply with ICD-10-CM Coding 
guidelines. The guidelines state that a manifestation code is not appropriate as a primary diagnosis as the 
etiology should be sequenced first.  
 
We looked at the file and Medicare rules. Diagnosis code R40.2420 has a "code first" note in the ICD-10 
Manual. This means that it cannot be used as a primary diagnosis. 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 medical services provided on March 30, 2022, billed with codes 99291, 31500, and 
93010.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) kit 
sensor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria are not met. 
 
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 require 
frequent daily adjustments of insulin based on blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) kit sensor.