Persius/hicric huggingface dataset:
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 ernollee requires physician oversight at least 
three days a week and is willing to participate in inpatient rehab. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for admission to an IRF.  
 
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 clinical documentation shows that the enrollee requires ongoing physical and 
occupational therapy. The documentation does not support the medical necessity of an intensive rehabilitation 
regimen in an IRF setting. IRF criteria is not met.  
 
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 Innovamatrix ac, per square (sq) centimeter (cm) 
(A2001). 
 
You asked the Plan to pre-approve wound care services. You say that you are requesting reconsideration and 
have provided medical records for review. The Plan denied your request. The Plan says the records do not 
show that the enrollee has adequate blood flow to support wound healing. 
 
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 wound care services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical documentation supports that this enrollee is suffering with bilateral foot 
ulcerations. Medicare guidelines advise that in order for skin substitutes to be authorized, a wound must be 
nonhealing, and among other criteria there must be adequate blood flow to support tissue growth/wound 
healing. Medicare guidelines advise that they will pay for items or services that are medically reasonable or 
necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed 
body member. These must be safe and effective, not mainly for the convenience of the enrollee or the 
physician, not experimental or investigational, appropriate in that they are furnished in accordance with 
accepted standards of medical practice for the diagnosis or treatment of the enrollees condition, one that meets 
but does not exceed the enrollees medical need, and at least as beneficial as an existing and available 
medically appropriate alternative.  In this particular case the physical examination reveals that this enrollee, at 
least clinically, has significant peripheral vascular disease (PVD). Clinical examination reveals poor blood flow 
to the bilateral lower extremities with numerous PVD skin changes to bilateral feet. In order for soft tissue and 
skin tissue to regenerate, adequate blood flow is needed. In order for a skin substitute to incorporate and help 
heal an ulceration, adequate blood flow is needed. Adequate blood flow including an ankle-brachial index 
(ABI) of greater than 0.60 or a toe pressure of greater than 30 millimeters of mercury (mmHg) is necessary. 
Because this is not established in the current documentation, it is the reviewers opinion that the requested 
Innovamatrix wound dressing 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 wound care services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Innovamatrix ac, per square (sq) centimeter (cm) (A2001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on August 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99233 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded". 
 
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 use of code 99233 is not supported by the records provided. Our reviewer found that the documentation supports an appropriate 
exam, but not an appropriate history or a high level of medical decision making. 
 
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 the services (99233) provided on August 21, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 86922 and 86920 billed for date of service May 9, 
2023. 
 
You asked the Plan to pay for procedure codes 86922 and 86920. You say that these services were necessary 
and are not bundled services. The Plan denied your request. The Plan says that these codes cannot be paid 
because they have a status indicator of "X" on the physician fee schedule, meaning that they are a statutory 
exclusion. In addition, these codes are bundled. 
 
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 codes at issue are laboratory services which is not paid on the 
Physician Fee Schedule. This means that a status indicator of "X" does not mean that these services are not 
covered. In addition, we could not verify any other reason these services could not be paid as there is no 
bundling issue that could be found, and the Plan did not indicate the payment with which this code is bundled. 
The Plan has not substantiated their denial in this case. Therefore, we decided that the Plan has to pay for 
procedure codes 86922 and 86920 billed for date of service May 9, 2023.  
 
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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from January 31, 2022, to March 1, 
2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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's denial indicates that the FIPS state and county code 
reported on the claim does not correspond to the state and county in which home health services were provided. 
We reviewed the claim information in the case record. The FIPS code reported is 32003. We found that code 
32003 corresponds to the state and county in which services were provided, according to the medical records in 
the case file. The Plan has not provided any other rationale for denial. It is the Plan's responsibility to support 
its denial with evidence. In this case, the Plan's denial is not supported, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for home health services provided from January 31, 2022, to 
March 1, 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 the enrollee currently meets acute inpatient 
rehabilitation admission criteria under CMS guidelines. The Plan denied your request. The Plan says the 
enrollee's records do not show the need for an intensive team for care.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 21, 2022, to 
December 16, 2022. 
 You asked the Plan to pay for the home health services. You say that the required NOA is on file. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 21, 2022. The NOA was not received by the Plan until February 
17, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from November 21, 2022, to December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that you need the power 
wheelchair because you have had two spinal surgeries and are going for the third surgery. You also say that 
you have bad feet and knees. The Plan denied your request. The Plan says the requested powered mobility 
device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 group 2 standard power wheelchair. 
Our reviewer says that the requested wheelchair is not medically necessary. Our physician reviewer found you 
do not require a power wheelchair to perform MRADLs. 
 
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 group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 17, 2023, billed 
with procedure code 95970-59. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this service is bundled into payment 
of another 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, we have confirmed that code 95970 is a column II code to column I code 63688; however, 95970 
was billed with a modifier.  
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical records do not support the 
use of procedure code 95970 being billed with 63688, requirements were not met for the procedure to be 
deemed performed distinct from 63688. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 17, 2023, billed with procedure 
code 95970-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on October 28, 
2022. 
 
You asked the Plan to pay for the initial hospital care. You say that you would like this claim to be processed 
and paid as soon as possible. The Plan denied your request. The Plan says CPT code 99223 remains 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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 initial hospital care. Our reviewer found the 
documentation did not support a comprehensive history, a comprehensive examination, or medical decision 
making of high complexity for this brief encounter. Therefore, the code, 99233, is not sufficiently supported in 
the provided documentation. 
 
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 initial hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for the initial hospital care (99223) provided on October 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of nivolumab. 
 
You asked the Plan to pre-approve nivolumab. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this treatment plan is not supported by guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 nivolumab. Our reviewer says that the 
enrollee does not meet criteria for the requested use of nivolumab. Our physician reviewer found nivolumab is 
not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This use is not supported by one 
of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nivolumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of nivolumab.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. 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 Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Opdivo (Nivolumab) is not FDA approved 
and use is not approved by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. The use of nivolumab for astrocytoma is the subject of ongoing clinical trials. The service is 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856), electronic connection (E2311), and additional items and accessories (codes E2607, E2361, 
E1028, E1002, E2613, E0955, E1012, E0953, and E0960). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair, electronic connection, and additional 
items and accessories. You say that the enrollee's chair was destroyed in a house fire. The Plan denied your 
request. The Plan says the enrollee does not have a medical need for the single power option included with 
K0856 group 3 power wheelchair. The Plan also says an electronic connection is not medically needed as there 
is no need to control two power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with single power option (such as 
code K0856) is covered if the criteria listed in the Medicare rules section of this letter 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 a group 3 standard power wheelchair, 
electronic connection, and additional items and accessories. Our reviewer says that the enrollee does not meet 
the coverage criteria. Our physician reviewer found the enrollee has multiple sclerosis, and has impaired 
mobility and activities of daily living. The enrollee is able to feed themself. Our reviewer also found that the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 group 3 standard power wheelchair, electronic connection, and additional 
items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 standard power wheelchair with single power option (K0856), electronic connection (E2311), and 
additional items and accessories (codes E2607, E2361, E1028, E1002, E2613, E0955, E1012, E0953, and 
E0960).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798, 
billed for date of service January 17, 2023. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, and 87798. The Plan denied your 
request. The Plan says payment for codes 87150, 87481, 87641, 87653, and 87798, is bundled. 
 
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 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481, 87641, 87653, and 
87798, are column II codes to column I code 87801. 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 codes 87150, 87481, 87641, 87653, and 
87798, billed for date of service January 17, 2023.