Persius/hicric huggingface dataset:
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 is not progressing at a fast past and is 
not returning to his baseline which will affect his ability to return home. The enrollee cannot go to a SNF 
because he is a registered sex offender. The Plan denied your request. The Plan says the IRF care 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), home with home health services, or home with outpatient therapy. 
 
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 was admitted for surgical repair of a femur fracture after a fall. The 
enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation 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 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 the services (99223) provided on March 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and 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 problem(s) requiring 
admission are of high severity. Typically, 70 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 services. Our reviewer says that the use of code 99223 is not supported by the records provided. Our reviewer found that the three elements required to report 99223 are 
not present in the documentation. Also, admission status is not confirmed at the time of the service. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99223) provided on March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left ventricle lead and cardiac resynchronization 
therapy defibrillator (CRT-D) device (33225). 
 
You asked the Plan to pre-approve CRT-D. You say that you want to appeal this denial. The Plan denied your 
request. The Plan says the addition of a left ventricular lead and upgrade to CRT-D 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 CRT-D. Our reviewer says that the 
requested CRT-D is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is described as having controlled ventricular rate and relatively narrow QRS complex 
(114ms) without left bundle branch clock. The reviewer found that the guidelines would not support implant of 
a CRT-D. The reviewer found there is insufficient documentation to support the medical necessity for 
implantation of a CRT-D in this enrollees 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 CRT-D have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a left ventricle lead and cardiac resynchronization therapy defibrillator (CRT-D) device (33225).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rigid or flexible bronchoscopy (procedure codes 31623, 
31624, 31628, and 31629) provided to the enrollee on March 8, 2022. 
 
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 denied codes remain 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 the denied codes is: 
 
CPT 31623: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing or protected 
brushings 
 
CPT 31624: 
 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar 
lavage 
 
CPT 31628: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung 
biopsy(s), single lobe 
 
CPT 31629: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle 
aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)  
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical documentation shows 
that there were specimens sent to the lab from this patients procedures, but the medical documentation does 
not support the billing of these procedure codes. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for rigid or flexible bronchoscopy (procedure codes 31623, 31624, 31628, and 31629) provided to 
the enrollee on March 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (procedure code 99220) rendered on 
November 1, 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 documents don't support this level of care. 
 
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 99220 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and 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 problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee received an 
emergency department (ED) evaluation, not an observation stay. Furthermore, the patients complaint, care and 
disposition were not of high-complexity. As such, the billing of CPT 99220 is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial observation care (procedure code 99220) rendered on November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of an IRF admission. 
 
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 that 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 metabolic encephalopathy and COVID-19 infection. Your medical problems are stable. 
You do not have complex nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee needs continued nursing services. The 
Plan denied your request. The Plan says the continued SNF care is not medically necessary, and the enrollee 
signed a valid Notice of Medicare Non-Coverage (NOMNC). 
 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology testing (88307) provided on August 24, 
2022. 
 
You asked the Plan to pay for surgical pathology testing. You say that you disagree with the denial and 
submitted additional documentation for reconsideration of the claim. 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. 
 
We find that CPT code 88307 is not supported in the medical record. Specifically, the records show that the 
enrollee was in an inpatient setting from August 23, 2022, through August 25, 2022. Per Medicare guidelines, 
an independent laboratory may not bill for pathology services for services furnished to a hospital inpatient or 
outpatient. Based on this information, we decided that Medicare rules for coverage of surgical pathology 
testing have not been met. Therefore, we decided that the Plan does not have to pay for surgical pathology 
testing (88307) provided on August 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF care 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 that at the current functional level, 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 in an 
IRF. The documentation does not support the necessity for admission to an IRF and the complexity of the enrollee's nursing, rehabilitation, and medical needs does not require an IRF stay with an interdisciplinary 
approach to rehabilitative care. While the enrollee may have a need for physical therapy and/or occupational 
therapy, the enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in 
an SNF. 
 
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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of breast implant on same day of mastectomy (ie, 
immediate) rendered on May 6, 2022. 
 
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 records do not support 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 19340 is "Insertion of breast implant on same day of 
mastectomy (ie, immediate)." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support the use of procedure code 19340 as the patient had previously undergone a mastectomy. There is a 
more appropriate procedure code. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for insertion of breast implant on same day of mastectomy (ie, immediate) rendered on May 6, 
2022.
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 currently meets acute 
LTACH admission criteria. The Plan denied your request. The Plan says the enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital, and there are no issues for which 
LTACH may offer a therapeutic advantage. 
 
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 
current acute care hospital receiving 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on August 24, 2022. 
 
You asked the Plan to pay for drug testing. You say that the drug testing services were medically necessary. 
The Plan denied your request. The Plan says the condition of the enrollee did not meet the Medicare rules for 
approval of definitive urine drug testing (UDT) for 22 or more drug classes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say a drug test may be reasonable and necessary for 
patients with known substance abuse or dependence, only when the clinical presentation has changed 
unexpectedly and one of the above indications is met. The records show the diagnosis is medication 
management of long-term (current) drug therapy. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing (G0483) provided on August 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95907 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for procedure code 95907. You say that the service was medically necessary. 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 95907 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 95907 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95907 billed for date of service August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with an oncologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that your surgeon for breast cancer as well as 
cardiologist is in Upland. She stated that she is trying to keep her care team in proximity to ensure the best care 
she can possibly have. She is also in need of transportation an if her care is centralized this will be an easier 
task to schedule. The Plan denied your request. The Plan says you must use network providers to get your 
medical care and services. Comparable providers are available in network. Transportation is also available for 
contracted providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99204) with an oncologist to be provided by an out-of-network (OON) provider.