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 not strong enough, and the hospital's 
rehabilitation is capable of addressing your area for improvement better. The Plan denied your request. The 
Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block. 
 
You asked the Plan to pre-approve a lumbar/sacral facet joint block. You say that the records provided support 
the need for the requested injection services. The Plan denied your request. The Plan says the requested 
injection services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions performed under ultrasound 
guidance are not considered medically reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a lumbar/sacral facet joint block. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
chronic low back pain. The physical exam and symptoms support the diagnosis of facet syndrome. However, 
the physician plans on using ultrasound guidance. 
 
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 lumbar/sacral facet joint block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lumbar/sacral facet joint block.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that 
there is no need to control the power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are covered under 
certain medical 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 the requested services. Our physician 
reviewer found that you have a past medical history of multiple comorbidities and falls with functional 
mobility impairments. Authorization for group 2 power wheelchair with power functions and upgraded 
electronics with connection from joystick to power functions is being requested. The Plan has agreed to pre-
approve all except for upgraded electronics. The clinical documentation shows that you have limited range of 
motion and functional impairments of upper limbs and there are 3 approved power functions. Therefore, an 
expandable control system is 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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve an expandable control system.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not able to continue with private pay at a 
nursing facility, that is not providing the intensive therapies that the enrollee needs to maintain a normal life. 
The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this enrollee 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 
15, 2021, through April 30, 2021. 
 
You asked the Plan to pay for the SNF care as billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the provider did not send the required 5-
day MDS assessment. 
 
The Plan must follow Medicare rules. Medicare rules say the MDS must be completed for payment to be 
approved.  
 
We looked at the file and Medicare rules. In this case, a 5-day MDS was not submitted by the provider. Based 
on this information, we decided that Medicare rules for coverage of the SNF care as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided 
from April 15, 2021, through April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on March 1, 2022. 
 
You asked the Plan to pay for subsequent hospital care (99231). You say that the records support that this was 
performed by the provider and the claim denied as a duplicate in error. You say that the claim should be 
reprocessed for reimbursement according to the contract. The Plan denied your request. The Plan says a 
modifier was not billed to 99231 was unrelated from procedure code 44050. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for certain 
procedures includes payment for the certain services related to the surgery when furnished by the physician 
who performs the surgery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of subsequent hospital care (99231) have not been met. Specifically, there is no indication this service 
was unrelated to the procedure performed on February 26, 2022. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (99231) provided on March 1, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on January 14, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that you would like this claim reprocessed as this 
testing is approved for coverage by Medicare. The Plan denied your request. The Plan says that there is a Local 
Coverage Determination (LCD) that indicates that any panel that tests for the FANCC gene is noncovered. 
They argue that since this panel includes that specific gene, the denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on January 14, 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 group 3 power wheelchair with multiple power 
options represented by code K0861, and power wheelchair accessories represented by codes E1007, E2311, 
E1012, E2361, E1028, E2377, E0955, K0040, E2607, E2313, E2620, and E2209. 
 
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options and related 
power wheelchair accessories. You say that you are unable to sit for long periods of time without pain and this 
necessitates frequent position changes. You say that the items prescribed are medically necessary and that 
without them your quality of life is suffering. You say that you are not comfortable sitting at 90 degrees and 
require the tilt and recline. You say that you need to use the expandable controls through a joystick so you can 
reach them without hindering the support and rehabilitation of your hips and back. You say that the 
documentation provided supports the need for all of the requested items. The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for coverage of a power wheelchair with multiple power 
options as there is no documentation showing the enrollee is high risk for development of skin ulcers. 
 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 group 3 power wheelchair with 
multiple power options and related power wheelchair accessories. Our reviewer says that the requested items 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee 
does not have the conditions that warrant 2 power seat options and the associated accessories. He does not 
require bladder catheterization, he does not have spasticity, and he does not have increased risk of pressure 
sores that require recline position. He has adequate strength in his right hand, so the expandable controller is 
not necessary. The request exceeds the device requirements necessary to meet his needs. 
 
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 group 3 power wheelchair with multiple power options and related power 
wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair with multiple power options represented by code K0861, and power wheelchair 
accessories represented by codes E1007, E2311, E1012, E2361, E1028, E2377, E0955, K0040, E2607, E2313, 
E2620, and E2209.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of the extracranial arteries, complete 
bilateral study for the enrollee. 
 
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 requested service is not medically necessary, and we cannot say this test is necessary 
at this time. 
 
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 at issue is the medical appropriateness and necessity of carotid doppler imaging in this patient, with 
physical exam revealing normal carotid pulses and no bruits. A previous carotid study in 2019 was normal. The 
documentation does not support the rationale for this imaging study. The guidelines do not support a need for 
carotid duplex scan extracranial bilateral study (93880). As a result, at this time cardiac doppler imaging would 
not be considered medically appropriate and necessary in this patients clinical 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a duplex scan of the extracranial arteries, complete bilateral study for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1930, L2820) provided on March 30, 2022. 
 
You asked the Plan to pay for orthotics. You say that these items are supported in the records. The Plan denied 
your request. The Plan says there is not a proof of delivery for these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. A delivery ticket or 
other delivery documentation was not included in the submitted records. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for orthotics (L1930, L2820) provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00731) provided to the 
enrollee on January 19, 2022. 
 
You asked the Plan to pay for the services. You say that this denial is not correct. The Plan denied your request. 
The Plan says only one anesthesia code is allowable for the same date of service. 
 
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 00731 is "Anesthesia for upper gastrointestinal 
endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified." 
 
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 describes that 
CPT 00731 was billed twice - CPT 00731 AA 7 units, and CPT 00731 AA 59 10 units. The documentation 
includes one anesthesia report with a start time of 09:25, and end time 10:28. A second anesthesia report with 
start time 08:36 and ended at 08.58 with a procedure report for foreign body removal was also included. In this case, billing the same procedure twice on same date of service is not supported. The medical record should 
have clear documentation why a second procedure was performed, and could not be performed during the first 
procedure. In this case, this service cannot be verified. 
 
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 anesthesia services (procedure code 00731) provided to the enrollee on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visit on June 01, 2021. 
 
You asked the Plan to waive the copayments for office visit. You say that you did not have an office outpatient 
visit that day, you had an outpatient surgery. Please remove this claim. The Plan denied your request. The Plan 
says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each specialist visit, including outpatient clinic visits.  
 
You must pay a $40 copayment for each specialist visit, including outpatient clinic visits. Covered services 
include but are not limited to services in an emergency department or outpatient clinic, such as observation 
services or outpatient surgery. Therefore, results in the total cost sharing amount of $40. 
 
 You have been asked to pay a $40 copayment for office visit. Office visits fall within the Outpatient hospital 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for office visit on June 01, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy evaluation (97163) billed on January 3, 
2022. 
 
You asked the Plan to pay for the physical therapy evaluation (97163). The Plan denied your request. The Plan 
says procedure codes 97112, 97530, 97112, 97530, 97112, 97530 have been overturned. The Plan also says the 
medical records submitted do not support procedure code 97163. 
 
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 97163 is physical therapy evaluation: high complexity, 
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities 
that impact the plan of care; An examination of body systems using standardized tests and measures addressing 
a total of 4 or more elements from any of the following: body structures and functions, activity limitations, 
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and 
Clinical decision making of high complexity using standardized patient assessment instrument and/or 
measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient 
and/or family. 
 
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 physical therapy evaluation (97163). Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the medical record does not include a high complexity physical therapy evaluation to meet the 
criteria for CPT code 97163. 
 
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 physical therapy evaluation (97163) have not been met. Therefore, we 
decided that the Plan does not have to pay for the physical therapy evaluation (97163) billed on January 3, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning cushion identified with code E0190. 
 
You asked the Plan to pre-approve a positioning cushion. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the documentation does not support that this item is covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. The 
documentation did not include medical records to support the need for the requested item. Therefore, we 
decided that the Plan does not have to pre-approve a positioning cushion identified with code E0190.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 10, 2022.