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

 
We decided that the Plan has to pay for a revision of total knee arthroplasty (27486) provided on August 3, 
2021. 
 
You asked the Plan to pay for a revision of total knee arthroplasty. You say that the service at issue was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that the service at issue was not 
billed appropriately. 
 
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 27486 is "Revision of total knee arthroplasty, with or without allograft; 1 component." 
 
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 a revision of total knee arthroplasty. Our reviewer says that 
the billed code meets criteria for reimbursement. Our reviewer found that the operative report describes a 
revision of the polyethylene liner, which is considered a component of the knee. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a revision of total knee arthroplasty have been met. Therefore, we decided that 
the Plan has to pay for a revision of total knee arthroplasty (27486) provided on August 3, 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 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. The 
enrollee's rehab can be safely provided at a lower intensity and 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection with Protext (Wharton's Jelly) (Q4246). 
 
You asked the Plan to pay for Protext (Wharton's Jelly). You say that the service at issue was medically 
necessary and is covered by Medicare. The Plan denied your request. The Plan says rules for payment have not 
been met because the service at issue is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for Protext (Wharton's Jelly). Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that Protext is an experimental/investigational approach to chronic ankle pain.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Protext (Wharton's Jelly) have not been met. Therefore, we decided that the 
Plan does not have to pay for an injection with Protext (Wharton's Jelly) (Q4246).  
 
Your complaint about receiving erroneous or incomplete information about the enrollees benefits from a 
representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance 
that must be answered by the Plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from September 22, 2021, to September 29, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you have never 
received a bill for this much before. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
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 a $225 
copayment per day for days 1-7 for inpatient hospital care.  
 
Records show that you were in the hospital for 6 days.  You were charged a $225 copayment per day, for a 
total of $1350.  You have been asked to pay a $225 copayment per day for days 1-7 for the inpatient hospital services. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for inpatient hospital services you received from September 22, 
2021, to September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic services (97530) provided on September 27, 
2021. 
 
You asked the Plan to pay for the therapeutic services. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says there is a more appropriate 
code for the services that were performed. 
 
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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Certified 
Occupational Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the 
therapy services were being rendered. The incident-to requirements have not been met in this case. Based on 
this information, we decided that Medicare rules for coverage of the therapeutic services have not been met. 
Therefore, we decided that the Plan does not have to pay for the therapeutic services (97530) provided on 
September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 15, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on March 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D radiographic procedure coded as 76376 provided on 
November 17, 2021. 
 You asked the Plan to pay for the 3D radiographic procedure. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
billed as required by Medicare coding regulations. 
 
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, we have confirmed that code 76376 
is a column II code to column I code 78226. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 3D radiographic procedure coded as 76376 provided on 
November 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower spine 
(72148). 
 
You asked the Plan to pre-approve MRI of the lower spine. You say that this is medically necessary and 
reasonable. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the lower spine. Our reviewer 
says that the requested imaging service is not medically reasonable and necessary. Our physician reviewer 
found that the review indicates that the enrollee is a 69-year-old female with right-sided lumbago sciatica. 
There are no documented physical exam abnormalities and no previous lumbar spine X-rays. There is no 
documentation of previous non-medical conservative therapies such as physical therapy or a home exercise 
program. There is no specific clinical rationale for the requested MRI of the lower spine. The review has 
determined that the requested MRI of the lower spine is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the lower spine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of the lower spine (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care coded 99233 provided on 
February 7, 2021. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like this claim reprocessed 
based on supporting medical records. The Plan denied your request. The Plan says the documentation does not 
support payment for the services 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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the subsequent hospital care. Our reviewer says that the 
documentation does not support for the hospital care as billed. Our reviewer found the reviewed documentation 
did not indicates that for the notes in question, medical decision making was of high complexity. The review 
has determined that the documentation did not support the billed CPT code 99233. 
 
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 subsequent hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care coded 99233 provided on February 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were compliant with regulations for 
billing. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim billed a place of service as 81, an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the enrollees sample was obtained at the independent laboratory. 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 the Guardant360 testing provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on December 1, 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 the provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit rendered on December 1, 2021.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and are 
currently unstable for transfer to an LTACH. 
 
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. You appear 
to be improving but require short-term additional acute care services that can safely be administered at the 
current facility for the time being. You do not require services at the LTACH that are not already available at 
the current facility. There are no services at the LTACH that you require that are not already available and 
covered at the current facility. Our physician reviewer found that your condition does not meet Medicare 
criteria for LTACH services. 
 
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 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. Your rehab can be safely 
provided at a lower intensity and alternate setting in a skilled nursing facility setting or in-home with therapies. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) provided on November 14, 2021. 
 You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 computed tomography (CT) scan of the head or brain (70450) 
provided on November 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical procedures on arteries and veins (36247, 37252, 
and 37253) provided on October 4, 2021. 
 
You asked the Plan to pay for the surgical procedures. You say that the requested assistant surgeon was 
medically necessary. The Plan denied your request. The Plan says this claim has not been billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that if the database contains 
an assistant at surgery indicator of 1 for the surgical procedure in question, Medicare has determined that an 
assistant is not medically necessary. Assistant surgeons will not be paid for these procedures. Medicare rules 
say that an add-on code is eligible for payment only if it is reported with an appropriate primary procedure 
performed by the same practitioner. 
 
We looked at the file and Medicare rules. In this case, CPT code 36247 has an assistant at surgery indicator of 
1 in the Medicare Fee Schedule Database indicating that the assistant is not medically necessary. Based on this, 
this code as billed with the assistant at surgery modifier will not be paid. Furthermore, we have confirmed that 
coded 37252 and 37253 are add-on codes to the primary procedure code 36247. Since 36247 is not eligible for 
payment, the corresponding add-on codes will not be paid as well. Based on this information, we decided that 
Medicare rules for coverage of the surgical procedures have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical procedures on arteries and veins (36247, 37252, and 37253) provided on 
October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 11, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on November 11, 2021.