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

 
We decided that the Plan does not have to pay for the selective catheter placement (36215) provided on August 
25, 2021. 
 
You asked the Plan to pay for the selective catheter placement (36215). The Plan denied your request. The Plan 
says CPT code 36215 is not supported by the clinical documentation in the operative report submitted and is 
denied. 
 
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 36215 is selective catheter placement, arterial system; 
each first order thoracic or brachiocephalic branch, within a vascular family. 
 
  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 selective catheter placement (36215). Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the procedure report describes the left subclavian vein was catheterized and left lower extremity 
venogram was performed. In this case, documentation does not support selective catheter placement, arterial 
system, each first order thoracic or brachiocephalic branch, and the procedure cannot be verified as performed. 
 
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 selective catheter placement (36215) have not been met. Therefore, we 
decided that the Plan does not have to pay for the selective catheter placement (36215) provided on August 25, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral extremity angiography rendered on May 4, 
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 procedure code 75716 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 75716 (bilateral extremity angiography) and 37229 
(endovascular revascularization). Code 75716 is a column II code with a modifier indicator of 1 when billed 
with column I code 37229. Code 75716 was not billed with an appropriate modifier to allow for separate payment. The file does not support the -XU modifier as a separate and distinct procedural service. Therefore, 
we decided that the Plan does not have to pay for the bilateral extremity angiography rendered on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensor; invasive (e.g., subcutaneous), disposable, for use 
with interstitial continuous glucose monitoring system, one unit = 1 day supply (CPT code A9276). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says this item is not covered by Medicare of the health plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the item have not been met. The rules say that continuous glucose 
monitors (A9276) are considered precautionary and therefore non-covered under the DME benefit. Therefore, 
we decided that the Plan does not have to pre-approve sensor; invasive (e.g., subcutaneous), disposable, for use 
with interstitial continuous glucose monitoring system, one unit = 1 day supply (CPT code A9276).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil 5MG tablet (CPT code J8499). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Tadalafil is a self-administered drug and not covered by the enrollee's Part B 
benefits.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tadalafil 5MG tablet (CPT 
code J8499).  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 at the current level of function with low tolerance to therapies, the enrollee will not 
tolerate IRF intensity of therapies.  The enrollee's rehabilitation can be safely provided at a lower intensity and alternate setting such as in a skilled 
nursing facility. Documentation does not support the necessity for admission to 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to go to the out-of-network rehabilitation 
hospital because you would be able to receive dialysis. You say you do not want to be taken back and forth 
between locations for dialysis. The Plan denied your request. The Plan says authorization denied because IRF 
is not medically necessary, and your needs can be met at a lower level of care such as a skilled nursing facility 
(SNF). 
 
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 are medically stable and do not need close supervision by a physician 3 times per 
week for the ongoing management of any active or acute exacerbation of chronic medical problems. You do 
not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump (99190 and 99191), 
autologous blood or component (86891) and red blood cells (P9022) provided on October 29, 2021. 
 
  You asked the Plan to pay for assembly and operation of pump (99190 and 99191), autologous blood or 
component (86891) and red blood cells (P9022). You say that the services were ordered by the patient's in-
network surgeon and provided at the in-network facility that have established the services as the standard of 
care for the surgical procedure. You say that you are requesting reprocessing of this claim at the patient's in-
network benefit level. The Plan denied your request. The Plan says non-physician services provided to 
inpatients which must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for inpatient hospital services under the 
Inpatient Prospective Payment System (PPS). All items and non-physician services furnished to inpatients must 
be furnished directly by the hospital or billed through the hospital under arrangements. 
 
We find that CPT codes 99190, 99191, 86891 and P9022 are not supported in the medical record. Specifically, 
non-physician services provided to inpatients must be furnished by the hospital or billed through the hospital. 
Based on this information, we decided that Medicare rules for coverage of assembly and operation of pump 
(99190 and 99191), autologous blood or component (86891) and red blood cells (P9022) have not been met. 
Therefore, we decided that the Plan does not have to pay for assembly and operation of pump (99190 and 
99191), autologous blood or component (86891) and red blood cells (P9022) provided on October 29, 2021.
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 enrollee meets Medicare criteria for IRF and will 
benefit from rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. 
The Plan says authorized denied because IRF is not medically necessary and the enrollee's needs can be met at 
a lower level of care such as a skilled nursing facility (SNF), outpatient setting or home health care. 
 
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 has no acute medical problems, is medically stable and does not 
need close physician supervision 3 times per week (at a minimum) for the ongoing management of any active 
or acute exacerbation of chronic medical problems. The enrollee does not need intensive therapies, consisting 
of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy 
in 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission to be 
provided by a network facility. 
 
You asked the Plan to pre-approve the SNF admission. You say that the SNF admission is medically necessary. 
The Plan denied your request. The Plan says authorization denied because the SNF admission is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as outpatient therapy or home care 
services.  
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled 
nursing service needs that require skilled nursing services, including the specialized skill, knowledge and 
judgment of a skilled professional nurse required to safely and effectively provide medically necessary and 
reasonable treatment. There are identifiable skilled therapy service needs that require skilled therapy services, 
including the specialized skill, knowledge and judgment of a qualified therapist required to safely and 
effectively provide medically necessary and reasonable treatment. The enrollee does not require skilled nursing 
or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission to be provided by a network facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osteoarthritis knee (L1851), back brace (L0650), and add 
on for knee brace (L2397), provided on October 6, 2021. 
 
You asked the Plan to pay for the knee and back brace. You say that the items were medically necessary. The 
Plan denied your request. The Plan says the member obtained these items through an unsolicited call by the 
DME company. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the knee and back 
brace have not been met. Therefore, we decided that the Plan does not have to pay for the osteoarthritis knee 
(L1851), back brace (L0650), and add on for knee brace (L2397), provided on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tilt shower chair. 
 
You asked the Plan to pre-approve a tilt shower chair. You say that the requested item is necessary. The Plan 
denied your request. The Plan says the item is primarily medical in nature and therefore, not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a tilt shower chair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from August 
13, 2021, to September 12, 2021. 
 You asked the Plan to pay for the SNF services. You say that these services are covered by Medicare. The Plan 
denied your request. The Plan says the enrollee's condition did not required skilled care. 
 
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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee is an 86 year old female 
with dementia, depression and failure to thrive. From a nursing perspective, the enrollee received oral 
medications and had stable vital signs.  She was alert with confusion, her appetite was fair to poor, and she 
could self-propel her wheelchair. The enrollee did not receive nor require skilled therapy for the dates in 
question. The enrollee had no identifiable skilled nursing or therapy needs that needed to be provided on a daily 
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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from August 13, 2021, to September 12, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport provided on April 9, 
2021. 
 
You asked the Plan to pay for the ambulance transport. You say that the patient could not be moved safely by 
other means due to their condition. The Plan denied your request. The Plan says these ambulance services were 
not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says 
that these ambulance services were not medically necessary. Our physician reviewer found the patient is a 94 
year old female who presented to the emergency department with left shoulder and chest wall pain and was 
found to have no acute issue after workup. She was discharged with a sling and Norco for pain.  
 It was noted that she was on hospice. She was transported via ambulance and her vitals were stable. The 
enrollee has a history of of gait abnormality, breathing difficulty, and dementia. The medical records do not 
show that other forms of transport were contraindicated. 
 
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 ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for non-emergent ambulance transport provided on April 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission to be 
provided by a network provider. 
 
You asked the Plan to pre-approve the SNF admission. You say that you cannot safely return home yet. You 
say you are unable to navigate stairs and would not be able to access your bedroom and bathroom in your 
home. The Plan denied your request. The Plan says authorization denied because the SNF admission is not 
medically necessary and that your needs can be met at a lower level of care, such home health services. 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled 
nursing service needs that require skilled nursing services, including the specialized skill, knowledge and 
judgment of a skilled professional nurse required to safely and effectively provide medically necessary and 
reasonable treatment. There are identifiable skilled therapy service needs that require skilled therapy services, 
including the specialized skill, knowledge and judgment of a qualified therapist required to safely and 
effectively provide medically necessary and reasonable treatment. You do not require skilled nursing or therapy 
services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the skilled nursing facility (SNF) admission to be provided by a network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from July 
14, 2021, to August 12, 2021. 
 You asked the Plan to pay for the SNF services. You say that these services are covered by Medicare. The Plan 
denied your request. The Plan says the enrollee did not receive a SNF level of care during these dates of 
service. 
 
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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the patient received oral medications, but 
her vital signs were stable and she was alert with confusion. She had physical and occupational therapy 
evaluations in the SNF, but had no skilled needs identified.  The records show that she was independent with 
functional mobility. The patient had no identifiable skilled nursing or skilled therapy needs and needed to be 
done on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from July 14, 2021, to August 12, 2021.