Persius/hicric huggingface dataset:
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 are requesting reconsideration for the denial of 
an IRF admission based on medical necessity. The Plan denied your request. The Plan says the request for an 
IRF admission is not shown to be 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 99153. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 99153. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99153 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99153 billed for date of service July 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing for 22 or more drug classes (G0483) 
billed for date of service May 27, 2022. 
 
You asked the Plan to pay for definitive drug testing. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 G0483 is: Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the case record does not 
contain a physician order for drug testing for 22 or more drug classes. Based on this information, we decided 
that Medicare rules for coverage of definitive drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for definitive drug testing for 22 or more drug classes (G0483) billed for date of 
service May 27, 2022.
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 are unable to move around freely and before 
your accident, you were independent. The Plan denied your request. The Plan says criteria for admission to the 
IRF setting have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for casting supplies (Q4006) provided on August 31, 2022. 
 
You asked the Plan to pay for the casting supplies. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
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 Q4006 is not supported in the medical record. Specifically, the records provided show 
that a splint was used on the date of service in question. There is no documentation of the enrollee receiving a 
cast on this date. Based on this information, we decided that Medicare rules for coverage of the casting supplies 
have not been met. Therefore, we decided that the Plan does not have to pay for casting supplies (Q4006) 
provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80349 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 80349. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 80349 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 80349 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 80349 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 80349 billed for date of service April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that you provided medical records to support payment. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on May 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says this request does 
not meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Feraheme. Our physician reviewer found the provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
20, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service September 20, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2022, to October 3, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2022, to October 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic risk assessment testing (81439) 
provided September 17, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the provider who referred this test did believe 
this was a necessary test to render on the enrollee, and therefore should be covered and re-evaluated. The Plan 
denied your request. The Plan says Medicare denies coverage for all cardiovascular genetic risk assessment 
panels for patients with suspected or documented cardiovascular disease. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
cardiovascular genetic risk assessment testing (81439) provided September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that this is a covered lab services and your lab is the 
only one that performs this testing. The Plan denied your request. The Plan says you billed with an incorrect 
place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service May 5, 
2022. 
 
You asked the Plan to pay for procedure code A4550. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code A4550 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 99212. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99212 is bundled into payment for code 99213. 
 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 99212 
is a column II code to column I code 99213. 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 procedure code 99212 billed for date of service July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99140 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee is new to your office and 
seeking treatment. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-adherent bandage, elastic, non-knitted/non-woven, 
width greater than or equal to 3 inches and less than 5 inches, per yard (code A6454). 
 
You asked the Plan to pre-approve self-adherent bandage, elastic, non-knitted/non-woven, width greater than or 
equal to 3 inches and less than 5 inches, per yard. You say that the requested self-adherent bandage is 
medically necessary. The Plan denied your request. The Plan says the records indicate that the member's wound 
is not a wound caused by a surgical procedure and is not being treated with debridement. The records indicate 
this wound is related to an abscess. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve self-adherent bandage, elastic, non-
knitted/non-woven, width greater than or equal to 3 inches and less than 5 inches, per yard. Our reviewer says 
that the requested self-adherent bandage is not medically necessary in this case. Our physician reviewer found 
that the enrollee is a 73-year-old with a healing wound being treated with dressing changes. The provided 
records described the enrollee with an abscess without recent surgery or debridement procedure as required to 
meet criteria for continued wound dressings. Therefore, this request for self-adherent bandage for wound care 
does not meet Medicare coverage criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of self-adherent bandage, elastic, non-knitted/non-woven, width greater than or 
equal to 3 inches and less than 5 inches, per yard have not been met. Therefore, we decided that the Plan does 
not have to pre-approve self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to 3 
inches and less than 5 inches, per yard (code A6454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99217 billed for May 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99217 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 99217 is observation care discharge includes services on 
the date of observation discharge (can only be used on a calendar day other than the initial day of observation). 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, there is no documentation of 
observation care discharge day management. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99217 billed for May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thread carpal tunnel release surgery. 
 
You asked the Plan to pre-approve thread carpal tunnel release surgery. You say that the requested thread 
carpal tunnel release surgery is medically necessary. The Plan denied your request. The Plan says the requested 
thread carpal tunnel release surgery is experimental. 
 
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 thread carpal tunnel release surgery. 
Our reviewer says that the requested thread carpal tunnel release surgery is not considered medically 
reasonable and necessary. Our physician reviewer found the enrollee has carpal tunnel syndrome. The enrollee 
had tried splinting without benefit. The provided documentation did not clearly describe all the conservative 
and other previous treatments tried and failed to help justify surgery. There was no report of steroid injections, 
physical therapy, ergonomic changes. Also, there is currently insufficient supportive evidence from high 
quality studies to suggest thread carpal tunnel release is superior to standard surgery. Therefore, this request for 
thread carpal tunnel release surgery will be considered not medically 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 thread carpal tunnel release surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve thread carpal tunnel release surgery.