Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010 x4). 
 
You asked the Plan to pre-approve surgical placement of implant body (D6010 x4). You say that this is 
jeopardizing your health and affecting your ability to eat properly. You say you are afraid it will get worse 
without treatment. The Plan denied your request. The Plan says the request for D6010 x4 exceeds plan limits 
and cannot be covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on May 25, 2023 when the Plan authorized 
surgical placement of implant body (D6010 x2).  Therefore, we decided that the Plan does not have to pre-
approve surgical placement of implant body (D6010 x4).
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 the care needed to return home. The Plan denied your request. The Plan says the services that the 
enrollee needs can be provided safely in another setting such as a skilled nursing facility, home with home 
health services or home with outpatient therapy. 
 
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. The enrollee has had a 
decline from their baseline level of function and would likely benefit from occupational and physical therapies 
and assistance. The records do not indicate that they would require the intensity of therapies provided in an 
acute inpatient rehabilitation. 
 
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 hospital discharge day management (99239) provided on 
July 20, 2022. 
 
  You asked the Plan to pay for hospital discharge day management (99239). You say that the evaluation and 
management service supports the level of service assigned and is considered medically necessary. The Plan 
denied your request. The Plan says the medical records submitted do not support hospital discharge 
management of more than 30 minutes was performed. 
 
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 is hospital discharge day management; more than 30 
minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the medical records do not 
document that more than 30 minutes of discharge management services was performed as required by the 
procedure code billed. Based on this information, we decided that Medicare rules for coverage of hospital 
discharge day management (99239) have not been met. Therefore, we decided that the Plan does not have to 
pay for hospital discharge day management (99239) provided on July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service November 
25, 2022. 
 
You asked the Plan to pay for procedure code 87640. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 87640 is bundled into 
payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. 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 87640 billed for date of service November 25, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee due to the complexity of their many ongoing medical issues and the need for continued close 
monitoring. The Plan denied your request. The Plan says they will continue to cover medically necessary acute 
and critical care at the current facility until the enrollee's condition is stable for transfer to an alternate level of 
care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital evaluation and management (EM) services 
provided on September 14, 2022, billed with code 99223. 
 
You asked the Plan to pay for the EM services as billed. You say that this code was correctly selected. The Plan 
denied your request. The Plan says the 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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We asked our 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 EM services as billed. Our reviewer says 
that the billed code is not supported. Our reviewer found the enrollee was a then 79-year-old woman with a 
medical history that included end-stage chronic obstructive pulmonary disease, coronary artery disease, 
hypertension, morbid obesity, and pneumonia. The History and Physical note includes a History of Present 
Illness, Review of Systems, Objective documentation, and an Assessment/Plan. The available documentation in 
the case file is insufficient to demonstrate that a comprehensive history was obtained from the enrollee on the 
date at issue. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital evaluation and management (EM) services provided on September 
14, 2022, billed with code 99223.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 tthe 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 acute inpatient rehabilitation facility.  here 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 three (3) visits weekly to regain or maintain the 
enrollee's 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy (PT) visits. 
 You asked the Plan to pre-approve home health services. You say that continued home health PT is needed. 
The Plan denied your request. The Plan says the services are not medically necessary beyond what was 
approved. 
 
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 member is 
an 85-year-old male with a medical history including Parkinson's disease who has been receiving skilled 
physical therapy in the home due to an abnormal gait with weakness. The documentation indicates his function 
has improved, and he has been authorized to have sufficient physical therapy visits to establish a home exercise 
program. 
 
In this case, the documentation does not support that the member requires additional skilled rehab services to 
provide treatment that is medically necessary. The member does not require additional skilled rehab services to 
effectively provide treatment, care, and/or services in order to improve the members condition, perform a 
maintenance program to maintain the members condition and/or prevent deterioration.  The member has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  
 
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 additional home health physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found this enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an outpatient. This has not been tried and shown to fail. Medicare 
does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator (E0466).
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 and lower levels 
of care cannot provide the care the enrollee needs. The Plan denied your request. The Plan says the services the 
enrollee needs can be provided safely in another setting such as a skilled nursing facility, home with home 
health services or home with outpatient therapy. 
 
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 has had a decline from their baseline level of function and would likely 
benefit from occupational and physical therapies and assistance for fall prevention. However, the enrollee does 
not require the intensity of therapies provided in an acute inpatient rehabilitation. The enrollee is requiring 
contact guard to stand by assistance now. Therefore, the acute inpatient rehabilitation admission 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you would like to appeal this decision. 
The Plan denied your request. The Plan says this request is not medically necessary.  

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have an effective treatment plan and require repetitive 
exercise to improve strength and balance. Repetitive exercise is not a skilled need, and you have an effective 
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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 15 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01638 x 116 and 99100) provided on 
October 28, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed and are not supported by the records. 
 
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 01638 is anesthesia for open or surgical arthroscopic 
procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; total 
shoulder replacement. 
 
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 anesthesia services. Our reviewer found for code 01638, 
the documentation submitted was reviewed and does not meet criteria. The procedure report documents 
anesthesia start time at 07:28 and end time 09:24. In this case, 116 units are not supported. To report anesthesia 
time is to record it in minutes. One unit of time is recorded for each 15-minute increment of anesthesia time. 
For example, a 45-minute procedure, from start to finish, would incur three units of anesthesia time. Being 
exact is required, since Medicare pays to one-tenth of a unit. Do not estimate the time or round up or down 
inappropriately. For example, for a 63-minute procedure, one would receive 4.2 time units (four time units x 15 
minutes plus 1/5th of a time unit, or 0.2).  Units billed cannot be verified. Furthermore, 99100 has a status 
indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. 
 
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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services (01638 x 116 and 99100) provided on October 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95907-26 x2 and 95886-26-59 billed for date 
of service November 21, 2022. 
 
You asked the Plan to pay for procedure codes 95907-26 x2 and 95886. You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says the number of units billed exceeds 
the maximum allowed. Procedure code 95886 is an add on code and was billed without a valid primary 
procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 95907 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Procedure code 95886 is an add on code that was billed without a valid primary 
procedure code and cannot be paid. Based on this information, we decided that Medicare rules for coverage of 
procedure code 95907-26 x2 and 95886-26-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95907-26 x2 and 95886-26-59 billed for date of service November 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(64628). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's records do not show clear evidence that the enrollee's pain is 
vetebrogenic, and do show evidence on magnetic resonance imaging (MRI) suggesting other obvious causes of 
the enrollee's low 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 the service. 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 a magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease (DJD) or foraminal stenosis. The cause of back pain is not 
clear. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve (64628).