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

 
We decided that the Plan has to pay for skilled nursing services (99309) provided on November 20, 2022. 
 
You asked the Plan to pay for skilled nursing services. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says that a corrected claim is needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan does not provide a clear explanation for denial in this case. 
The procedure code and diagnosis codes used on this claim are all valid. The Plan has failed to substantiate a 
clear reason for denial in this case. Therefore, we decided that the Plan has to pay for skilled nursing services 
(99309) provided on November 20, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, chest (E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the enrollee 
has head and neck lymphedema swelling as a result of squamous cell cancer of the oral cavity requiring 
surgery, radiation, and lymph node dissection. The requested devices are medically necessary for the enrollee. 
The Plan denied your request. The Plan says criteria is not met for the requested service as lymphedema does 
not extend onto the chest and there is no documentation of a failed 4-week trial using a basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, chest (E0657).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided from October 11, 2021, to 
October 21, 2021. 
 
You asked the Plan to pay for laboratory services. You say that you were encouraged to find a laboratory on 
your own because your provider ordered many tests for you. You chose this provider because they offered a 
large discount. You say that although these providers do not participate with Medicare programs, they are 
eligible to do so, and these services should be paid. The Plan denied your request. The Plan says no payment is 
made for services performed by providers who do not accept Medicare payment. 
 
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. Please also note that the receipts provided for these services indicate 
that they are not intended for submission of health insurance claims and should only be considered for Health 
Saving and Flexible Spending Account reimbursement only. Therefore, we decided that the Plan does not have 
to pay for laboratory services provided from October 11, 2021, to October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74230, 72040, 70100, 70310, 74240, and 
99204 billed for date of service November 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were performed at the request of the 
primary care physician. The Plan denied your request. The Plan says the documentation does not support the 
place of service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the claim was billed with place of service code 11, an office setting. The medical records provided 
do not indicate the services were provided in an office. Codes 74230 and 74240 involve the use of contrast 
media, which is excluded from coverage as portable x-ray services. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 74230, 72040, 70100, 70310, 74240, and 99204 billed for date of service 
November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent (64493) and 
injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (64494). 
 You asked the Plan to pre-approve facet joint injections. You say that you feel services should be approved 
because you have had previous physical therapy and MRIs completed through workman's compensation which 
is why the Plan does not have any record of it. The information provided should be sufficient for injection 
approval. The Plan denied your request. The Plan says clinical documentation received and available for review 
does not show you have been treated with therapy or home exercises for at least 6 weeks in the last 6 months, 
there is no imaging attached (such as MRI), and there is no documentation of your pain level assessment. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have a history of low back pain due to lumbar spondylosis. You have had 
injections in the remote past with "good relief," have used Lidoderm patches, and have completed a course of 
physical therapy. No pain assessment was documented. An MRI of the lumbar spine was completed on 
December 1, 2016; however, the results of that imaging are not included. Your provider has recommended 
facet joint injections under image guidance. There is no clinical documentation indicating you have attempted 
and/or failed noninvasive conservative management (as tolerated). There is also no clinical documentation 
stating you do not have any non-facet pathology as evidenced by clinical assessment or radiological studies. 
The review has determined that the facet joint injections are not medically necessary for you. You do not meet 
criteria for the facet joint injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve injection(s), diagnostic or therapeutic agent (64493) and injection(s), diagnostic 
or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image 
guidance (64494).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on April 1, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is not consistent with the procedure. 
 
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 71271 is computed tomography, low dose for lung cancer 
screening, without  contrast material(s). 
 
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 radiology services provided. Our reviewer says that 
documentation does not support the billed code Our reviewer found the acceptable diagnosis codes for this 
service are: Z87.891, F17.210, F17.211, F17.213, F17.218, and F17.219. Therefore, procedure code 71271 is 
not eligible for reimbursement consideration. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiology services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for radiological services provided on April 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent transportation trips (A0100). 
 
You asked the Plan to pre-approve additional transportation trips. You say that the enrollee needs additional 
transportation for dialysis. The Plan denied your request. The Plan says the request exceeds the enrollee's 24 
covered transportation trips allowed by the plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergent transportation trips (A0100).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for presumptive drug testing (80307) provided on August 6, 2021. 
 
You asked the Plan to pay for drug testing. You say that this service was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says that this service is included in another 
service billed on this date, or another provider billed and was paid for code 80307 on the same date. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no evidence to show that any other provider 
has billed or been paid for code 80307 or any other presumptive drug testing code for the date in question. The 
only other service shown to have been billed for this date is code G0480, which is definitive drug testing and is 
considered a separate service. In addition, the rule the Plan applies to indicate that 80307 is inclusive to another 
code applies to validity testing, which is often reported as mass spectrometry and does not include presumptive 
drug testing. The Plan has failed to substantiate the denial of this service with evidence and a relevant citation. 
Therefore, we decided that the Plan has to pay for presumptive drug testing (80307) provided on August 6, 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot be safely discharged at this time. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and need assistance with your basic 
needs. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and your 
needs can be met in other settings. 
 
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 you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on June 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services should be covered. The Plan denied 
your request. The Plan says the services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that paramedic intercept services are only covered under 
certain indications. 
  
 The Plan has confirmed that the paramedic company does not have a contract with the volunteer ambulance 
company that provided the transport services. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the paramedic 
intercept services provided on June 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a joint surgery of the right knee (29881). 
 
You asked the Plan to pre-approve a joint surgery of the right knee. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a joint surgery of the right knee. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures. Peer-reviewed literature, as noted above, 
states that conservative care measures are first-line treatment for meniscal tears. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 joint surgery of the right knee have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a joint surgery of the right knee (29881).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous carotid artery stenting (PCAS). 
 
You asked the Plan to pre-approve PCAS. 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 PTA is covered when used under 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 PCAS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found guidelines are clear that such a procedure 
would be authorized only if there were accompanying symptoms or if the lesion narrowing were 80% or more. 
In their absence, percutaneous transluminal angioplasty (PTA) and stent placement would not be considered 
medically necessary. As such, PCAS would not be considered to be appropriate or medically necessary in this 
enrollee's 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 PCAS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous carotid artery stenting (PCAS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says records do not show detailed 
measurements, as required for reassessment. There is no documentation of truncal edema on physical 
examination or of a 4-week trial of the basic pump. The enrollee does not meet criteria for approval of the 
requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 9, 2022, to 
March 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.89, described as other 
specified sepsis, and secondary diagnosis code R65.20, described as severe sepsis without septic shock. We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that documentation does not support the billed codes. Our physician 
reviewer found that the enrollee is a 78-year-old female who presented to the emergency department with 
nausea, vomiting and chills. She was diagnosed with colitis. She was treated with antibiotic therapy and IV 
fluids for dehydration. The kidney function remained stable and improved with hydration. She did not have 
altered mentation and her vital signs remained stable. There was no evidence of life-threatening organ 
dysfunction due to dysregulated host response to an infection or persistent hemodynamic instability.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 9, 2022, to March 21, 2022, at the Diagnosis Related Group 
(DRG) originally billed.