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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Favorable

 
We decided that the Plan has to pay for procedure codes 76937 and 99152 provided on January 30, 2023. 
 
You asked the Plan to pay for procedure codes 76937 and 99152. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that 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 76937 is Ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure). We find that CPT code 76937 is supported in the medical 
record. Specifically, the radiology report documents that "the right internal jugular vein was evaluated with 
ultrasound and found to be patent. A permanent image was stored. The vein was accessed with realtime 
ultrasound guidance using a microintroducer needle." 
 
Additionally, the definition of code 99152 is Moderate sedation services provided by the same physician or 
other qualified health care professional performing the diagnostic or therapeutic service that the sedation 
supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's 
level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or 
older. We find that CPT code 99152 is supported in the medical record. Specifically, the procedure report 
documents "moderate sedation was performed by the physician including the presence of an independent 
trained observer that assisted in monitoring the patient's level of consciousness and physiological status. 
Following the administration of midazolam and fentanyl the physician spent 30 minutes of continuous face-to-
face time with the patient."  This record is also documented in the procedure log. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 76937 and 99152 
have been met. Therefore, we decided that the Plan has to pay for procedure codes 76937 and 99152 provided 
on January 30, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 0245U billed for date of service April 28, 2023. 
 
You asked the Plan to pay for procedure code 0245U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that payment for code 0245U is bundled into 
payment for code 0081U. 
 
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 0245U 
is not a column II code to code 0081U.  
 
The rules also 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 provided no other 
rationale or supporting evidence. Therefore, we decided that the Plan has to pay for procedure code 0245U 
billed for date of service April 28, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 provided on October 6, 2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for procedure code 99232 is included in the global surgery 
payment for procedure code 61312 provided on October 7, 2022. Separate payment cannot be made for 
procedure code 99232. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99232 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99232 provided on October 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular abdominal aortic aneurysm repair surgery. 
 
You asked the Plan to pre-approve vascular surgery. You say that the enrollee has an aneurysm that needs to be 
treated as soon as possible. The Plan denied your request. The Plan says the aorta is less than 3 centimeters in 
diameter and generally the aortic diameter needs to be at least 3 centimeters. Standard of care for the enrollee's 
condition would involve anti-impulse therapy with a beta blocker and potentially a calcium-channel blocker 
and surveillance. 
 
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 vascular surgery. 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 that the aneurysm is sacular and no evidence of a penetrating ulcer or pseudoaneurysm. It appears this was a known aneurysm, but there does not appear to be a 
discussion as to if there has been a change in the aortic morphology over time. There is no discussion in the 
assessment as to what features are present in this case that would necessitate repair of an aortic aneurysm this 
small. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vascular surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve endovascular abdominal aortic aneurysm repair surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injections provided on January 
12, 2023. 
 
You asked the Plan to waive the coinsurance for the drug injections. You say that you would like help with the 
cost of this injection. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the drug injections. This item/service falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the drug injections provided on January 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on February 26, 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function".  
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 99285 is 
not supported by the records provided. Our reviewer found that there is no documentation of medical decision-
making of high complexity. 
 
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 (99285) provided on February 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 9, 2023, to March 
23, 2023, billed with procedure codes 97116-GP-CQ-59, 95735-GP-59, and 97530-GP-CQ. 
 
You asked the Plan to pay for the practitioner services provided. You say that that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says documentation does not support the billed 
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 codes 97116-GP-CQ-59, 95735-GP-59, and 97530-GP-CQ is 
therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing), self-care/home 
management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety 
procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes, therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to 
improve functional performance), each 15 minutes. 
 
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 codes. Our reviewer found plan of care would include diagnosis, 
long-term treatment goals, type, amount and duration of therapy, as well as certification from prescribing 
healthcare provided. In this case, medical record does not include amount and duration of therapy and certified 
by prescribing physician. 
 
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 February 9, 2023, to March 23, 2023, billed 
with procedure codes 97116-GP-CQ-59, 95735-GP-59, and 97530-GP-CQ.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 13 units of code 87798 provided on December 23, 2022. 
 
You asked the Plan to pay for 13 units of code 87798. The Plan denied your request. The Plan says the billed 
units are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure 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 to pay for 13 units of code 87798 Our reviewer says 
that 13 units of code 87798 are not supported by the records provided. Our physician reviewer found that the 
laboratory report does not support the 13 units billed. An additional unit was unable to be verified, as this 
procedure was not found in medical record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 13 units of code 87798 have not been met. Therefore, we decided that the Plan 
does not have to pay for 13 units of code 87798 provided on December 23, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for continued skilled nursing facility (SNF) services after October 8, 2023. 
 
You asked the Plan to pay for SNF care. You say that you were discharged sooner too soon. The Plan denied 
your request. The Plan says that these services are not medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before October 8, 2023. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pay for continued skilled nursing facility (SNF) services after October 8, 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: 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 meets the full criteria for approval and 
will benefit from an interdisciplinary approach to their rehabilitation program. The Plan denied your request. 
The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the 
requirements for approval.  
 
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 lumbar spine surgery. Medical problems are stable. 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 this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 23, 2023, billed with 
procedure codes 97110-GP, 97112-GP, 97116-GP-59, and 97530-GP-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 documentation does not support the billed 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 codes 97110-GP, 97112-GP, 97116-GP-59, and 97530-GP-59 
is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and 
endurance, range of motion and flexibility, therapeutic procedure, 1 or more areas, each 15 minutes; 
neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities, therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing), and therapeutic activities, direct (one-on-one) patient contact (use of 
dynamic activities to improve functional performance), each 15 minutes. 
 
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 codes. Our reviewer found that the medical records provided does 
not include the time that was spent for each of the therapeutic exercises performed, therefore these procedures 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 23, 2023, billed with procedure codes 
97110-GP, 97112-GP, 97116-GP-59, and 97530-GP-59.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve ultrasound. You say that you are appealing this denial. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan and the enrollee can be treated within the 
Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ultrasound to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on April 28, 2023, to May 17, 
2023. 
 
You asked the Plan to pay for the office visits. You say that you did not know the provider was out-of-network, 
and did not realize you had no out-of-network benefits. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visits provided 
on April 28, 2023, to May 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair and accessories. 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the enrollee resides in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair and accessories.