Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from March 12, 2023, to 
March 15, 2023.  
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG is 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 871. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee was diagnosed with pneumonia. The enrollee had documented tachycardia. The enrollee was 
afebrile and had normal respiratory rate, and normal white count. The criteria for sepsis was not met, according 
to the documentation. Diagnosis A41.9 was not supported. The documentation more supports DRG 194 rather 
than 871.  
 
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 March 12, 2023, to March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prosthesis, flex-walk system 
(L5981) and an all-lower extremity prosthesis, multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve all-lower extremity prosthetics. You say that the enrollee requires a new 
replacement due to physiological changes in his residual limb and increased body weight. His current 
prosthesis cannot be adjusted or modified to meet his basic needs. The Plan denied your request. The Plan says 
the enrollee's foot is under warranty. If a new prosthetic is needed, the provider needs to work with the 
manufacturer to obtain a new one under warranty. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of all-lower extremity prosthetics have not been met. Specifically, Medicare does not cover 
replacement prosthetics for items under warranty. Therefore, we decided that the Plan does not have to pre-
approve an all-lower extremity prosthesis, flex-walk system (L5981) and an all-lower extremity prosthesis, 
multi-axial rotation unit (L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 rendered on November 6, 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 Current Procedural Terminology (CPT) code 99306-25-AI (1 Unit) 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 99306 is "Initial nursing facility 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, 45 minutes are spent at the bedside and on the patient's facility 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of high complexity, or that 
45 minutes were spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99306 rendered on November 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97598 billed for date of service April 19, 
2023. 
 You asked the Plan to pay for procedure code 97598. You say that this code was denied as in conflict with 
11044. You have provided documentation to support this procedure with line item 97597 (which was paid) due 
to the size of the wound. The Plan denied your request. The Plan says payment for code 97598 is bundled into 
payment for code 11044. 
 
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 97598 
is a column II code to column I code 11044. 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 code 97598 billed for date of service April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapies provided on January 26, 2023, to February 
23, 2023. 
 
You asked the Plan to pay for physical therapies. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the provider does not have active CMS certification 
Number (CCN) on file. 
 
The Plan must follow Medicare rules. Medicare rules say that Licensed Practical Nurse (LPN) is among the 
provider types that are not eligible to enroll in Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapies have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapies provided on January 26, 2023, to February 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88307 and 11102 provided on June 30, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We looked at the file and the rules. We find that the services, billed with CPT codes 88307 and 11102 were not 
reported correctly. Code 88307 was billed with primary diagnosis code R52. Medical records were not 
provided to determine if this diagnosis code is suitable as the primary diagnosis. Code 11102 was billed with 
modifier 79. This modifier is used to identify a service that is unrelated to a surgical procedure. There is not 
sufficient documentation to show that this modifier is suitable for payment. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 88307 and 11102 provided on June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this care to return to prior level of 
function. The Plan denied your request. The Plan says the enrollees medical condition does not require IRF 
services, and care can be provided in another setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: 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 patient meets medical necessity defined by 
Medicare guidelines for an admission to an IRF. The Plan denied your request. The Plan says based on 
Medicare guidelines, the IRF services requested 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 at the current functional level, the patient does not need intensive therapies consisting 
of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. The 
complexity of the patient s medical, rehabilitation, and nursing needs combined does not require an acute 
hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. Our reviewer also 
found that the patient s rehabilitation needs can be safely provided in an alternate and low intensity setting, 
such as in a skilled nursing facility.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tissue Cypher Test (0108U). 
 
You asked the Plan to pre-approve the Tissue Cypher Test. The Plan denied your request. The Plan says this 
test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that current molecular diagnostic tests that identify 
individuals with upper gastrointestinal metaplasia, dysplasia, and neoplasia are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tissue Cypher Test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Tissue Cypher Test (0108U).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says there is not enough research 
to show that intraosseous radiofrequency ablation of the basivertebral nerve (e.g., 
Intracept system) improves net health outcomes in enrollees with vertebrogenic back pain. 
 
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 an 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 magnetic resonance imaging (MRI) showing only modic changes without 
facet joint disease or stenosis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 20, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have provided a copy of the claim and the 
visit note to support payment. The Plan denied your request. The Plan says two of the billed diagnosis codes 
cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M54.12 has an Excludes1 note in relation to G56.21. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on April 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 15, 2023, to 
March 16, 2023. 
 
You asked the Plan to pay for the home health services. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says you did not bill and appropriate Type of Bill code 
for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that home health agencies must bill the correct type 
of bill code.  Except for replacement or voided claims, home health agencies must bill type of bill 0329.  In this 
case, you billed with the incorrect type of bill code of 0322. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from February 15, 2023, to March 16, 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 a lower level of care of any kind, including home 
health and/or skilled nursing, is not enough to adequately help the enrollee return to their prior level of function 
and improve their quality of life. You would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says the enrollee's condition does not meet Medicare guidelines for services in 
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 complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional 
status.  The enrollee can receive further services at a lower 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the RESPeRATE device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has not been found to be reasonable or 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this therapy is not covered for treatment of ordinary muscle tension states or for psychosomatic 
conditions. The documentation indicates the enrollee is requesting this device for insomnia and hypertension 
which are not covered indications for this device. The requested item is 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the RESPeRATE device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided June 1, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you request reconsideration and payment in 
full for the toxicology drug screen performed. The Plan denied your request. The Plan says under Medicare 
rules, the number of definitive urine drug classes requested are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was referred for extensive definitive drug testing. The documentation 
does not support that extensive drug testing was 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug classes (G0483) provided 
June 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alveoloplasty. 
 
You asked the Plan to pre-approve an alveoloplasty. You say that the enrollee needs this dental work. The Plan 
denied your request. The Plan says  the enrollee does not have a jaw fracture, and the medical criteria have not 
been met.  
 
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 an alveoloplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there were no x-rays included with the review. There was also no periodontal charting included. 
Based off the limited information provided, 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an alveoloplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an alveoloplasty.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose computed tomography (LDCT) scan for lung 
cancer screening (71271) provided on April 14, 2023. 
 You asked the Plan to pay for the LDCT scan. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says there is insufficient evidence in the medical record to 
support that the criteria for this test were met. The claim was submitted with diagnosis code Z72.0, which is 
defined as, "tobacco use, not otherwise specified". This is not a  
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the medical records and the diagnosis submitted on 
the claim are insufficient to support that the enrollee has a tobacco smoking history of at least 20 pack years 
and is a current or former smoker who quit within the last 15 years. Therefore, we decided that the Plan does 
not have to pay for the low dose computed tomography (LDCT) scan for lung cancer screening (71271) 
provided on April 14, 2023.