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

 
We decided that the Plan does not have to pay for hospital care (99233) provided on September 10, 2022 to 
September 11, 2022. 
 
You asked the Plan to pay for the hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is 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 99233 is subsequent hospital care requiring two out of 
these three key components: a detailed interval history, a detailed examination and medical decision making of 
high complexity. 
 
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 hospital care. Our reviewer says that the billed code is 
not supported by the records. Our reviewer found no detailed history was included. The physical examination 
was not detailed. The patient appeared to be stable on the dates of service without need for high complexity 
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 hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital care (99233) provided on September 10, 2022 to September 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
November 10, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that medical records were provided. 
The Plan denied your request. The Plan says procedure codes 99100 and 99140 are considered bundled and not 
separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that the codes are not separately payable. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 99100 and 99140 billed for date of service November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision of hyperbaric oxygen therapy (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. 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 follows Medicare rules. Medicare rules say that no program payment may be made for HBO in the 
treatment of certain conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's 
wound has not demonstrated a failure of standard wound therapy. The right heel wound has improved in 
dimension and area. The review has determined that the enrollee does not meet the coverage criteria detailed in 
the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision of hyperbaric oxygen therapy (99183).
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 a home ventilator is medically necessary. 
The Plan denied your request. The Plan says the patient's needs can be met with bilevel positive airway 
pressure (BiPAP) with average volume-assured pressure support (AVAPS) capability. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the enrollee is a a 65-year-old 
female with past medical history of chronic obstructive pulmonary disease (COPD) and myopathy with poor 
muscle strength. The sleep study performed was negative for obstructive sleep apnea. Sleep oximetry 
performed was negative for desaturations of less than 88% for at least 2 hours during sleep. Arterial blood gas 
(ABG) study was not received. You stated that she requires a ventilator for Volume Assured Pressure Support 
therapy mode (VAPS), which can be delivered by bi-level PAP machine with AVAPS capability. 
 
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: 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet require daily skilled nursing and/or daily skilled rehabilitation 
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 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 and/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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imlygic (J9325). 
 
You asked the Plan to pre-approve Imlygic. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Imlygic. Our reviewer says that the 
requested use of Imlygic is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the requested drug is to be used in combination with immunotherapy. The reviewer found that the 
requested use of Imlygic is not FDA-approved for the enrollees diagnosis. The reviewer found that the requested use is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. Therefore, the reveiwer found that the requested use of Imlygic 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 Imlygic have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imlygic (J9325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care set, for negative pressure wound therapy 
electrical pump, includes all supplies and accessories (code A6550) provided on August 25, 2022. 
 
You asked the Plan to pay for the wound care set, for negative pressure wound therapy electrical pump, 
includes all supplies and accessories. You say that the supplies were medically necessary. The Plan denied your 
request. The Plan says you have exceeded the maximum allowed for a one-month period. 
 The Plan must follow Medicare rules. Medicare rules say that regardless of utilization, a supplier must not 
dispense more than a one (1)-month quantity at a time. 
 
We looked at the file and Medicare rules. The file shows you have exceeded the maximum allowed for a one-
month period. Based on this information, we decided that Medicare rules for coverage of the wound care set, 
for negative pressure wound therapy electrical pump, includes all supplies and accessories have not been met. 
Therefore, we decided that the Plan does not have to pay for wound care set, for negative pressure wound 
therapy electrical pump, includes all supplies and accessories (code A6550) provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (64490, 64491). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet all the criteria listed 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 the facet joint injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the patient has not had two (2) 
medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent 
minimum of 80% relief of primary pain. There was a subsequent therapeutic facet joint procedure at the same 
anatomic site which did not result in at least consistent 50% pain relief for at least three (3) months from the 
prior therapeutic procedure or at least 50% consistent improvement in the ability to perform previously painful 
movements and activities of daily living (ADLs) as compared to baseline measurement using the same scale. 
There is no documentation of why the patient is not a candidate for radiofrequency ablation (such as 
established spinal pseudarthrosis, implanted electrical device) in the medical record. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections (64490, 64491).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (20610-RT, 20610-LT, J7324-RT, J7324-LT, 
77002) provided on September 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is 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. 
 
We find that payment for CPT codes 20610 and J7324 is not supported in the medical record. Specifically, 
these codes were both billed with modifiers LT and RT on separate claim lines. Codes 20610-LT and J7324-LT 
were billed with a right-sided diagnosis code, and codes 20610-RT and J7324-RT were billed with left-sided 
diagnosis codes. Per Medicare rules, this is inappropriate billing. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met.  
 
In this case, we have also confirmed that code 77002 is an add-on code and has not been billed with a payable 
primary procedure code. As the primary procedure code (20610) is not payable in this case, the add-on code is 
also not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the services (20610-RT, 20610-LT, J7324-RT, 
J7324-LT, 77002) provided on September 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for metabolic encephalopathy and rhabdomyolysis after a fall. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain fused to high noble metal tooth #'s 
23, 24, and 26 (D6240). 
 
You asked the Plan to pre-approve the pontic - porcelain fused to high noble metal. You say that you cannot eat 
well. The Plan denied your request. The Plan says the documentation did not meet the criteria for pontic-
porcelain fused-high noble. 
 
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. The Plan covers the pontic - 
porcelain fused to high noble metal when the services are medically necessary and reasonable.  
 
 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 pontic - porcelain fused to high 
noble metal. Our reviewer says that the requested dental service is not medically necessary. Our physician 
reviewer found no retainer crown were indicated as abutments for a fixed bridge. A review of the 
documentation indicates that there are multiple missing mandibular teeth (#'s 18, 19, 23, 24, 25, 26, 29 and 30). 
Replacing the anterior teeth (#'s 23-26) with a fixed bridge is beyond the scope of the plan since a fixed bridge 
may be considered for coverage only to replace two adjacent mandibular anterior teeth when no posterior teeth 
are missing. A removable partial denture may be considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic - porcelain fused to high noble metal have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a pontic - porcelain fused to high noble metal tooth #'s 
23, 24, and 26 (D6240).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to lower the cost share for therapeutic radiology service. We decided that the 
Plan does not have to waive the cost share for therapeutic radiology service.  
 You asked the Plan to waive the cost share for therapeutic radiology services and lab services provided on 
March 1, 2022, to April 1, 2022. You say that you disagree with the cost share. The total amount you are being 
asked to pay is $2,955.23 for therapeutic services. The total amount for all services rendered is $2,965.23 
($2,955.23 + $10 =$2,965.23). The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to lower the cost share for therapeutic radiology service.  
 
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost sharing information. Your contract with the Plan says that enrollees must pay a 20% coinsurance for 
therapeutic radiology service. 
 
The Plan says that from March 1, 2022, you must pay $2,393.01 of the allowed amount of $11,964.55, for a 
therapeutic radiology service. Based on the Plan contract, however, you cannot be asked to pay more than a 
20% coinsurance for therapeutic radiology service. The correct coinsurance for the allowed amount is 
$2,392.91 $11,964.55 x 20% = $2,392.91). 
 
Therefore, we decided that the Plan has to lower the coinsurance therapeutic radiology service provided on 
March 1, 2022. 
 
We also decided that the Plan does not have to waive the cost share for therapeutic radiology service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for therapeutic radiology service. Therefore, we decided that the Plan does not have to waive the 
cost share for therapeutic radiology service. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary to provide you with 
intensive physical therapy to increase your motor function so you can return home independently. The Plan 
denied your request. The Plan says you do not meet all the required Medicare criteria for admission to an 
inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not need an intensive therapy program. You need routine physical and 
occupational therapy. Your therapy needs can be met in a low intensity alternate setting such as a skilled 
nursing 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 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 it is medically necessary. The Plan denied your 
request. The Plan says you do not meet the requirements for approval. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical management of coronary artery disease. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided 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.