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

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria for this therapy is not met. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee underwent breast reduction following radiation 
therapy. The record provided indicates that the nipple areolar complex is healing well. The records provided do 
not document the presence of an indication for the requested treatment for which coverage is available. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the requested treatment is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested treatment 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 ultrasound guided radiation therapy. 
Our reviewer says that the requested ultrasound guided radiation therapy not considered medically reasonable 
and necessary in this case. Our physician reviewer found the requested service is not the community standard 
of care. Therefore, the reviewer found that this service is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99217) provided on June 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that when a patient is admitted for observation care 
and then is discharged on a different calendar date, the physician shall report Initial Observation Care, from 
CPT code range 99218  99220, and CPT observation care discharge CPT code 99217.  
 
We looked at the file and Medicare rules. In this case, the claim was not billed with an Initial Observation Care 
code, from CPT code range 99218  99220, as required by 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 (99217) provided on June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (0295U) provided on May 4, 2022. 
 You asked the Plan to pay for laboratory testing. You say that this test was medically necessary and 
appropriate. The Plan denied your request. The Plan says this claim was billed with inconsistent diagnosis 
codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, 
right or is bilateral. If the side is not identified in the medical record, assign the code for the unspecified side. 
Codes for unspecified side should rarely be used, such as when the documentation in the record is 
insufficient to determine the affected side and it is not possible to obtain clarification. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory testing have not been met. Specifically, this claim was billed with ICD-10-CM codes 
D05.10 (intraductal carcinoma in situ of unspecified breast) and D05.11 (intraductal carcinoma in situ of right 
breast). This cannot be billed as both an unspecified laterality and a specified laterality. Therefore, we decided 
that the Plan does not have to pay for laboratory testing (0295U) provided on May 4, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88305 billed for date of service April 18, 2022. 
 
You asked the Plan to pay for procedure code 88305. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says that presumptive drug testing, reported with 
codes 80305-80307, is reported "per date of service" and shall not be reported with more than one unit of 
service per day. The service at issue was billed with 11 units; however, this service may not be reported with 
more than one unit per day. 
 
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 denied payment for procedure code 88305 based on 
rules which apply to code 80305. This rule does not apply to code 88305. Of note, code 88305 has a maximum 
unit limit of 16 per day under the Medicare Unlikely Edits. The documentation supports that code 88305 is the 
service at issue and the service which was billed by the provider; therefore, the Plans denial is not 
substantiated in this case. Therefore, we decided that the Plan has to pay for procedure code 88305 billed for 
date of service April 18, 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: 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 you do not feel that you will recover at home. You 
say that your wife is unable to care for you because of her own health issues. 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). 
 
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 were admitted for lumbar spine surgery and was discharged on November 29, 
2022. Your medical problems are stable, and there are no 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance and supervision. 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 program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve HBO therapy and physician attendance 
and supervision. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
in this case, the record indicates that the enrollee had a diabetic foot ulcer and required resection with flap. The 
flap has evidence of necrosis. The records provided do not indicate the vascular status of the enrollee or 
document adequate sufficient circulation for healing. The record does not indicate that the enrollee has a 
diabetic ulcer at this time or its Wagner grade. The elements of the coverage criteria are not satisfied. The 
requested service is not 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 HBO therapy and physician attendance and supervision have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) 
and physician attendance and supervision (99183).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 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. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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 pre-approve a sacroiliac (SI) joint injection (27096). 
 
You asked the Plan to pre-approve the injection. You say that this should be covered. You say that you are in 
pain every day. You also say that nothing else is helping. The Plan denied your request. The Plan says the 
requested injection 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 the injection. Our reviewer says that the 
requested SI joint injection is not considered medically reasonable and necessary in this case. Our physician 
reviewer found an SI joint injection is considered successful if there was a least 75% pain relief. The reviewer 
found that the provided documentation does not support that you experienced this. Therefore, the reviewer 
found that the SI join injection is 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac (SI) joint injection (27096).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve viscosupplementation injection. 
 
You asked the Plan to pre-approve viscosupplementation injection. 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 when there was no improvement in knee pain and 
functional improvement from a previous series of injections, a repeat series of injections will be considered not 
reasonable and necessary and will not be 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 viscosupplementation injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, there 
was no benefit from the previous Monovisc injection. The review has determined that the enrollee does not 
meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of viscosupplementation injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve viscosupplementation injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (61510) provided on May 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 We looked at the file and Medicare rules. Payment for the requested services (61510) is included in the global 
surgery payment for the procedure (61512) provided on April 30, 2022, which has a 90-day global period. 
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 (61510) provided on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) and harness (E2313). 
 
You asked the Plan to pre-approve an expandable controller and harness. 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 power wheelchair accessories are covered when 
specific criteria are met. 
 
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 an expandable controller and harness. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
enrollee has a neurologic disorder with functional deficits. The requested electrical accessories are not 
medically necessary as the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller and harness have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller (E2377) and harness (E2313).
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 the enrollee is ready for discharge and requires 
inpatient rehabilitation to regain maximum functionality after post-acute care and surgery. The Plan denied 
your request. The Plan says the IRF services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the complexity of 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: 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 SNF care is medically necessary. The Plan 
denied your request. The Plan says the SNF care is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as nursing or therapy services provided at home or in a provider's office. 
 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 based on the documentation, the enrollee no longer qualifies for SNF coverage. The 
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. The enrollee is consistently ambulating more than 100 feet and tending to activities of daily 
living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. As a practical matter, the enrollees care needs 
are custodial and can be provided at a lower level of care (ex. home, assisted-living, long-term 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93005 billed for date of service July 3, 2022. 
 
You asked the Plan to pay for the billed service. You say that the code is covered by the fee schedule. The Plan 
denied your request. The Plan says the code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 93005 is electrocardiogram, routine ECG with at least 12 
leads; tracing only, without interpretation and report. 
 We find that CPT code 93005 is a packaged code. Payment is packaged when billed on the same claim as a 
code 99284, which has a status indicator of V. Based on this information, we decided that Medicare rules for 
coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 93005 billed for date of service July 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. 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 June 2, 2022.