Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (15100, 15120, 15004, 15002, 
15271, 97605, 15272) provided on December 21, 2022. 
 
You asked the Plan to pay for the services. You say that these services were medically necessary and 
appropriate. The Plan denied your request. The Plan says it was not medically necessary for there to be an 
assistant surgeon for these services. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that this case 
pertains to skin grafting performed on a 69 year old female on the leg (8.5 x 3.5 cm) and foot (2 x 3.5 cm). At 
issue is payment for a physician assistant in this case and whether or not the surgical assistance was medically 
necessary. The documentation provided does not support medical necessity. 
 
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 pay for surgical assistant services (15100, 15120, 15004, 15002, 15271, 97605, 15272) provided on 
December 21, 2022.
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 these services are necessary for the enrollee to gain 
back their independence. The Plan denied your request. The Plan says the required services can be provided in 
an alternate setting.  
 
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 review indicates that the is only requiring standby assist to CGA for bed mobility 
and transfers and ambulating 130 feet with standby assist following hospitalization for COVID-19 infection 
and congestive heart failure exacerbation. The enrollee is near baseline level of function and does not require 
an intensive multidisciplinary rehabilitation program to achieve stated goals. The enrollee is now stable and 
does not have active comorbidities that require close supervision by a rehab physician or nurse. The complexity 
of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. There is a reasonable expectation that this enrollee will not 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on April 13, 2023. 
 
You asked the Plan to pay for the shingles vaccine. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover some vaccines under the Part D benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on April 
13, 2023.  
 
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053 and 99496 rendered on April 24, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 80053: 
 
Comprehensive metabolic panel 
 CPT 99496: 
 
Transitional care management services with the following required elements: Communication (direct contact, 
telephone, electronic) with the patient and/or caregiver within 2 business days of discharge High level of 
medical decision making during the service period Face-to-face visit, within 7 calendar days of discharge 
 
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 in terms of CPT 80053, the 
laboratory report does not include documentation of this laboratory test - a comprehensive metabolic panel - 
and therefore cannot be verified. 
 
In terms of CPT 99496, the procedure report describes that the enrollee was admitted to rehabilitation on 4/6/23 
and was home by 4/20/23. The date of service for the evaluation was 4/24/23. In this case, the face to face was 
performed with 7 days of discharge; however, communication with the patient and/or caregiver within 2 
business days of discharge was not found in medical record, as well as the documentation does not support a 
high level of complexity. Therefore, this procedure code 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 procedure codes 80053 and 99496 rendered on April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (NIV). 
 
You asked the Plan to pre-approve the NIV. You say that clinical records have been provided to support the 
medical necessity of these devices. The Plan denied your request. The Plan says ventilators used to provide 
continuous positive airway pressure (CPAP) or BiPAP therapy will be denied as not reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 the NIV. Our reviewer says that the 
requested NIV is not medically necessary in this case. Our physician reviewer found the enrollee has COPD 
and pulmonary hypertension with chronic hypoxemic respiratory failure on home oxygen. The enrollee's recent 
hospital stay shows acute improvement of his exacerbation using BiPAP with no further evidence to suggest 
failure of therapy or failure of BIPAP to require escalation of therapy to a ventilator.  
 
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 NIV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a non-invasive ventilator (NIV).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered orthosis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the current peer-reviewed medical 
literature does not support the use of the MyoPro device. Current clinical guidelines for adult stroke 
rehabilitation and recovery designate robotic therapy to be of "uncertain utility compared with dose-matched 
conventional upper limb exercise therapies" with unproven benefit in the home environment. The MyoPro is 
therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro powered orthosis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from January 19, 2023, 
to February 27, 2023.  
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG 558 was appropriate for the inpatient 
stay. 
 
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 DRG 919. 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 the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the billed DRG is not supported, as the enrollee underwent debridement of a persistent abscess with 
necrotizing tissue, not a surgical wound infection or dehiscence.  
 
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 rendered from January 19, 2023, to February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown for tooth #2 provided on April 10, 
2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the tooth must have 50% bone support for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the services 
when the services are medically necessary and reasonable.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that a periapical x-ray was included dated 12/14/2022. There was no periodontal charting or clinical notes included. The tooth 
shows a large amalgam filling extending onto the root surface of the tooth. There is severe bone loss around the 
tooth. A crown is not recommended for a tooth in this condition as the tooth has a guarded to poor prognosis. 
When teeth have severe bone loss, the tooth may be mobile, and may need extraction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a porcelain/ceramic crown for tooth #2 provided on April 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed for date of service May 10, 
2023. 
 
You asked the Plan to pay for the services. You say that this service was necessary and is supported as billed 
for separate payment. The Plan denied your request. The Plan says although a modifier was used to bypass the 
edit, the records do not support that this modifier was used correctly. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
provider reported CPT 69990 with modifier 59 to indicate a distinct procedural service. The provider 
documents microsurgical technique was performed for pre-procedure planning. This would be considered inclusive to the primary procedure. 
 
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 pay for procedure code 69990 billed for date of service May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93229 rendered on March 9, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93229 is "External mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified health care professional." 
 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 CPT 93229 is technical 
component of this service and includes all of the following within a course of treatment that includes up to 30 
consecutive days of cardiac monitoring: Patient hook-up and patient-specific instruction and education. 
Transmission and receipt of ECG. Analysis of ECG by non-physician. Therefore, this procedure 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 procedure code 93229 rendered on March 9, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the records provided support the need for SNF care. 
The Plan denied your request. The Plan says that the requirements for approval have not been met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has documented skilled nursing needs in the form of daily wound care. 
The enrollee did have documented skilled therapy needs, as he was functioning below his baseline and had not 
been shown to have reached a new lower plateau in function. Daily skilled services were required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. Records show that the enrollee has 
indeed made measurable progress while at the SNF.  While ongoing care may no longer be required, denial of 
the initial request is not supported by the records and should be overturned for coverage. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on April 10, 2023, to May 5, 
2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says these services are not covered by the Plan under any 
circumstance. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on April 10, 2023, to May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis; 
initial, up to 1 hour (96365), intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour 
(96366) and refilling and maintenance of portable pump (96521) provided on March 9, 2023. 
 
You asked the Plan to pay for intravenous infusion. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says codes 96365, 96366 and 
96521 remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 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 intravenous infusion. Our reviewer says that the services do 
not meet criteria for payment on this claim. Our reviewer found for CPT 96365 and 96366, medical records 
describe intravenous insulin treatment provided for an outpatient on March 9, 2023. In this case, there are more 
appropriate Healthcare Common Procedure Coding System (HCPCS) code that should be reported for these 
services provided. For CPT 96521, medical records do not include documentation of refilling and maintenance 
of portable pump. Was unable to cite report, as this procedure was not found in medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravenous infusion have not been met. Therefore, we decided that the Plan 
does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour 
(96365), intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour (96366) and refilling 
and maintenance of portable pump (96521) provided on March 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of the CardioMEMS. 
 
You asked the Plan to pre-approve the implantation of the CardioMEMS. You say that the requested service is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 implantation of the CardioMEMS. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a 
result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in 
this enrollee's 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 implantation of the CardioMEMS. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the implantation of the CardioMEMS.