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

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an 
implantable cardiac monitor (ICM). In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ICM in this enrollees 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 insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear stress test (78452). 
 
You asked the Plan to pre-approve a nuclear stress test. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a nuclear stress test. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no evidence provided that 
would support the need for radionuclide stress testing at this time. In summary, there is insufficient 
documentation to support the medical necessity for the requested cardiac stress testing in this enrollees 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 a nuclear stress test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a nuclear stress test (78452).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the compression device. We decided that the Plan does not have to 
pre-approve the mattress.  
 
You asked the Plan to pre-approve a group 2 powered pressure reducing mattress and a sequential compression 
device.. You say that this is medically necessary. The Plan says that this is not medically necessary. 
 
We decided that the Plan has to pre-approve the compression device.  
 
The Plan follows Medicare rules. Medicare rules say that services are covered if they are medically 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 for the compression device. Our reviewer says that the 
enrollee's sequential compression device is noted to be non-functional and therefore requires replacement. 
 
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 items have been met. Therefore, we decided that the Plan has to pre-approve 
the compression device.  
 
We also decided that the Plan does not have to pre-approve the mattress. 
 
The Plan follows Medicare rules. Medicare rules say that services are not covered if they are not medically 
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 for the mattress. Our reviewer says that the enrollee 
has reduced bed mobility due to weakness from multiple sclerosis. The enrollee is at risk for skin breakdown 
but is noted to have a Med Aire alternating pressure and low air loss bariatric mattress that is in good condition 
that is 1-2 years of age. The enrollee already has a powered pressure reducing air mattress that is functional and 
therefore does not need a replacement mattress. The enrollee also does not have pressure ulcers. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the mattress. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the records provided support the need 
for home health services. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that the enrollee requires additional skilled nursing services or skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to 
improve the enrollees condition, perform a maintenance program to maintain the enrollees condition and/or 
prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations.  The requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 rendered on August 8, 
2022. 
 
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 there are no results for the denied codes. 
 
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 87899: 
 
Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; not otherwise 
specified  
CPT 87900: 
 
Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics 
 
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 CPT codes in question are not 
supported. They require specification of the agents tested for. The results do not specify which agents were 
tested for and reported with these codes. 
 
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 87899 and 87900 rendered on August 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from February 23, 2022, 
to February 25, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration. The Plan denied your request. The Plan says the DRG 
was updated. 
 
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 734. 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 while the number of lymph nodes reviewed by the pathologist is identified, the number of lymph nodes 
removed by the surgeon is not identified. As such, the billing of 07TC0ZZ and 07TD0ZZ is not supported.  
 
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 February 23, 2022, to February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (K0108, 
E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. 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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, 
etc.).The enrollee does not require a separate display (i.e., for alternate control devices), other electronic 
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an 
attendant control. The documentation does not support that it is medically necessary to control the requested 
power options through the joystick (drive interface). The enrollee's upper extremity strength and functional 
ability as evidenced by being supervision for feeding should be sufficient to control any power options through 
their own switches. The documentation does not reveal that the E2377 Expandable Controller, E2313 
Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are 
medically necessary. The K0108 foot plate exceeds the enrollee's medical needs. It does not serve a primarily 
medical need. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional accessories for a power wheelchair (K0108, E2311, E2313, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 rendered on March 15, 
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 the denied codes is: 
 
CPT 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour  
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure) 
 
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 provided 
does not include sufficient documentation to validate the intravenous infusion codes. The medical records 
indicate that Outpatient Intravenous Insulin Treatment (OIVIT) was performed and a different code should be 
used to represent these services, therefore 96365 and 96366 cannot be verified. In addition, OIVIT regimen are 
nationally not covered by Medicare. 
 
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 96365 and 96366 rendered on March 15, 2023.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 20680. We decided that the Plan does not have to pay for 27335.   
You asked the Plan to pay for procedure codes 20680 and 27335 rendered on December 13, 2022.. You say 
that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 20680.  
 
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 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 for CPT 20680. Our reviewer says that the records 
support CPT 20680 as a separate and distinct procedure from CPT 27447. The procedure details cite the screw 
was then removed in its entirety in the femur and this was protruding into the future box cut. The tibial screw 
was needed to be removed as well. This screw was noted on x-ray to be in the planned cut site. The hardware 
removal was separate from the overall total knee replacement to allow for correct positioning of the implant. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
20680.  
 
We also decided that the Plan does not have to pay for 27335. 
 
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 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 for CPT 27335. Our reviewer says that the records do 
not support CPT 27335 as a separate and distinct procedure from CPT 27447. The procedure details cite a 
titrated synovectomy was performed around the patella. Patella tendon, quadriceps tendon all visualized the 
patella and minimize potential scarring and crepitus. A spacer block was utilized and the knee was found to be 
very well balanced in both flexion and extension not requiring any release. A titrated posterior synovectomy 
was performed in the medial and lateral compartments as well as into the notch. This was a part of the overall 
total knee replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 27335 have not been met. Therefore, we decided that the Plan does not have to 
pay for 27335. 
 
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 medical records provided support the need for 
IRF care. The Plan denied your request. The Plan says the enrollee does not meet the requirements. Services 
needed may be provided safely in 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. The enrollee 
was admitted for pleural effusion. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from April 
22, 2022, to April 30, 2022. 
 
You asked the Plan to pay for the services. You say that these services were reported appropriately. The Plan 
denied your request. The Plan says the rate code billed for these services is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. The documentation available 
for review that pertains to the appropriate look-back period does not support the enrollees functional score for 
physical therapy/occupational therapy or skilled nursing. The documentation available for review does not 
support the therapy or nursing levels claimed by the provider. The 1st and 3rd alphanumeric character in the 
PDPM were not correct. The partial adjustment to PDPM LEQE1 was appropriate. 
 
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 skilled nursing facility (SNF) services rendered from April 22, 2022, to April 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need skilled therapy services for walking, 
standing and moving.  The Plan denied your request. The Plan says the enrollee has no skilled nurse or therapy 
needs.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing services. While there are identifiable skilled 
therapy service needs, they are not required on a daily basis. The enrollee does not meet the severity of illness 
or intensity of service criteria for an inpatient basis in a SNF setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.