Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 84153 and 82607. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 82306.  
 
You asked the Plan to pay for procedure codes 84153, 82607, and 82306 provided on April 18, 2023. You say 
that you would like the Plan to reconsider their denial of payment. The Plan says that the services are not 
covered. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 84153 and 82607.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 84153 and 82607.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
82306. 
 
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 procedure code 82306 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 the services described by procedure code(s) 82306. 
 
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 an acrylic socket (L5629) and ultra-lightweight 
materials (L5940) for an approved lower limb prosthesis. 
 
You asked the Plan to pre-approve the prosthetic features. You say that these features are medically necessary. 
The Plan denied your request. The Plan says the requested items are non-covered under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that when an initial below knee prosthesis (L5500) or 
a preparatory below knee prosthesis (L5510, L5520,L5530, L5540) is provided, prosthetic substitutions and/or 
additions of procedures and components are covered in accordance with the functional level assessment except 
for codes L5629, L5638, L5639, L5646,L5647, L5704, L5785, L5962, and L5980 which will be denied as not reasonable and necessary. 
 
The rules also state that Codes L5940, L5950, and L5960 for ultra-light materials may only be used when 
materials such as carbon fiber, fiberglass, Kevlar, or other advanced composite lamination materials are used in 
the fabrication of a socket for an endoskeletal prosthesis. They are not used for ultralight materials used in 
other components of a prosthesis  e.g., knee/shin system, pylon, ankle, foot. For codes L5940, L5950, and 
L5960, the unit of service is per limb. 
 
We looked at the file and Medicare rules. Code L5629 is not covered for the preparatory prosthesis being 
provided (L5540). Ultra-light materials are not used for the socket on a preparatory prosthesis, therefore code 
L5940 is not eligible for coverage. Based on this information, we decided that Medicare rules for coverage of 
the prosthetic features have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
acrylic socket (L5629) and ultra-lightweight materials (L5940) for an approved lower limb prosthesis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (64635, 64636). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve. You say that 
this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary 
because the records show that the enrollee has not had at least 2 diagnostic medial branch blocks with each one 
providing a consistent minimum of 80% sustained relief of pain. 
 
The Plan follows Medicare rules. Medicare rules say that in order for thermal radiofrequency destruction of 
lumbar paravertebral facet joint nerves to be considered medically reasonable and necessary, patients must 
have had at least 2 MBBs, with each providing a consistent minimum of 80% sustained relief of primary pain. 
 
   
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 destruction by neurolytic agent, 
paravertebral facet joint nerve. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found our doctor found that there is no documentation submitted that indicates the previous medial 
branch blocks provided greater than 80% relief for 3 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint nerve have not been 
met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (64635, 64636).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation of conservative measures to include 6 weeks of recent 
physical therapy. The magnetic resonance imaging shows facet degenerative joint disease. 
 
   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 12 additional PT visits. We decided that the Plan does not pre-
approve the remaining 6 PT visits.  
You asked the Plan to pre-approve 18 additional physical therapy (PT) visits. You say that the additional PT 
visits are medically necessary for your recovery. The Plan says that the additional PT visits are not medically 
necessary. 
 
We decided that the Plan has to pre-approve 12 additional PT visits and does not have to pre-approve 
the remaining 6 PT visits. 
 
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 item/service at issue. Our reviewer 
says that 12 additional PT visits are medically necessary. Our physician reviewer found that you have made 
progress with therapy in terms of your independence with mobility and daily activities. You were re-evaluated 
for PT, specifically for knee pain on August 29, 2023. You made progress in terms of range of motion, motor 
strength and your lower extremity functional score. Therefore, the continued PT would be appropriate for your 
condition. In total, 12 additional PT visits can be considered medically necessary to maximize your progress 
and transition to a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 additional PT visits have been met. Therefore, we decided that the Plan has 
to pre-approve 12 additional PT visits and does not have to pre-approve the remaining 6 PT visits. 
 
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 has a serious, life-threatening 
constellation of acute medical problems that have left them at a functional status below their baseline, and as 
such requires close daily oversight of ccare by a physician in an inpatient setting. You would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the notes do not 
show that the enrollee's care specifically requires the involvement of a doctor in the field of Rehabilitation 
Medicine; the notes do not show that the enrollee has complex care needs that require a coordinated team approach; the notes do not show that the enrollee must have an intensive therapy program (3 hours a day, at 
least 5 days a week) in order to 
improve self-care functioning.  
 
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. The enrollee 
does require physical therapy and occupational therapy services, but the medical records provided do not 
clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. Provided medical 
records do not support that the intensive inpatient rehabilitation therapy program is necessary and that therapy 
at a lower level of care such as in a skilled nursing facility is not appropriate for the patient. Based on the 
medical records provided there is concern that the enrollee will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF given that their baseline is non-
ambulatory for the past 6 months. The medical records do not clarify that treatment at the skilled nursing 
facility level is not appropriate in this case.  
 
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: 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 medically necessary for the enrollee 
to receive physical and occupational therapy services to ensure a return home with significant gains toward 
their prior level of function. The Plan denied your request. The Plan says the records do not show that the 
enrollee needs an intensive team for their 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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99214 billed for date of service May 31, 2023. 
 
You asked the Plan to pay for code 99214. You say that the medical records show that this claim was billed 
correctly. The Plan denied your request. The Plan says code 99214 is not supported by the medical record. The 
records show that this service should have been billed with code 99213 instead. 
 
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 99214 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires at least two of these three key components: a 
detailed history; a detailed examination; medical decision making of moderate 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 patients and/or familys needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 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 code 99214. Our reviewer says that code 99214 is not 
supported by the medical record. Our reviewer found the complexity of problems addressed is moderate 
(exacerbation of chronic condition), the date is not applicable (NA) (no data reviewed or analyzed),and  the risk 
and complication was low (minor surgery without identified risk factors). This meets criteria of Low in 2 of 3 
categories, equaling 99213. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99214 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99214 billed for date of service May 31, 2023.
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's medical management and rehabilitation 
needs requires an inpatient rehabilitation stay and close physician supervision. The Plan denied your request. 
The Plan says the enrollee's condition does not meet all of the requirements for inpatient rehabilitation 
admission. The Plan says services may be provided at a lower level of 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: 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 want to go to the rehabilitation hospital where 
you were before. The Plan denied your request. The Plan says your condition does not meet all of the 
requirements for inpatient rehabilitation admission. The Plan says services may be provided at a lower level of 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) assessment using 
the ImpediMed L-Dex testing device. 
 
You asked the Plan to pre-approve the ImpediMed L-Dex testing device. You say that the enrollee is at high 
risk for developing lymphedema as a result of their treatments. You also say that using the ImpediMed L-Dex 
testing device is medically necessary. The Plan denied your request. The Plan says this 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 ImpediMed L-Dex testing device. 
Our reviewer says that the requested ImpediMed L-Dex testing device is not considered medically reasonable 
and necessary in this case. Our physician reviewer found the provided documentation does not indicate that the enrollee has any signs of developing lymphedema and has undergone just a sentinel node biopsy procedure that 
has a low risk of lymphedema.  Therefore, the reviewer found that the requested L-Dex testing device 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 the ImpediMed L-Dex testing device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) assessment using the 
ImpediMed L-Dex testing device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. The Plan denied your request. The Plan says 
the radiofrequency ablation 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 radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
the radiofrequency ablation is considered experimental therapy because of the wide variation in efficacy 
reported in the literature. Therefore, the request is not medically reasonable and 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.