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 the enrollee requires therapy services that would be 
received in an acute rehabilitation facility. The Plan denied your request. The Plan says ongoing skilled care 
can be provided in an alternative 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 is medically stable. There are no acute rehab nursing needs identified or 
documented. Document does not support necessity for admission to an IRF. The complexity of the enrollees 
medical, rehab, and nursing needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. The enrollees rehab 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo system. 
 
You asked the Plan to pre-approve the Barostim Neo system. You say that the Barostim Neo system is 
medically necessary. The Plan denied your request. The Plan says the requested Barostim Neo system is not 
medically necessary and unproven. 
 
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 Barostim Neo system. Our reviewer 
says that the requested Barostim Neo system is not considered medically reasonable and necessary in this case. 
Our physician reviewer found Baroreflex stimulation devices have been considered potential alternative 
treatments for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse 
generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one 
of the carotid arteries. In August 2019 the Food and Drug Administration (FDA) approved the system for use in 
patients with refractory heart failure who remain symptomatic despite treatment with guideline-directed 
medical therapy, are New York Heart Association (NYHA) Class III, have an ejection fraction less than 35%, 
and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement 
in normal daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There 
remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of the Barostim Neo in patient management. As a result, at this time the Barostim Neo system would 
not be considered medically reasonable and necessary in this patients 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 the Barostim Neo system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo system.
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 return to their prior level of functioning. The Plan denied your request. The Plan says ongoing skilled care 
can be provided in an alternative 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 is medically stable. There are no acute rehab nursing needs identified or 
documented. At the current functional level, the enrollee does not need intensive therapies. Document does not 
support necessity for admission to an IRF. The complexity of the enrollee's medical, rehab, and nursing needs 
does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab (88365, 88364, 88374) provided on March 17, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says one unit was already paid for this test. Records do not support multiple 
units. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 88365 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 88365. Codes 88364, & 88374 are also not supported. Multiple units and codes 
were billed for a single test on a single specimen. Based on this information, we decided that Medicare rules for 
coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab 
(88365, 88364, 88374) provided on March 17, 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 you need inpatient therapy because you are not 
mobile without the help of another person. The Plan denied your request. The Plan says an IRF admission 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 you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as 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: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not have daily skilled nursing needs that require 
the specialized skill, knowledge, and judgment of a skilled professional nurse. The Plan says that the services 
needed may be provided safely in a lower level of care. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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.
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 these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee's needs are currently being met. 
 
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 enrollee is receiving appropriate care in their current 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code K0005 for date of service December 27, 2022. 
 
You asked the Plan to pay for code K0005. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the item billed 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 K0005 is ultralightweight wheelchair. 
 
We find that CPT code K0005 is not supported in the medical record. Specifically, the documentation shows 
that a lightweight wheelchair was delivered. This means there is a more appropriate code to be billed for the 
item rendered. In addition, the order provided does not include a detailed description of the wheelchair. Based on this information, we decided that Medicare rules for coverage of code K0005 have not been met. Therefore, 
we decided that the Plan does not have to pay for code K0005 for date of service December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service April 13, 2023, to 
April 17, 2023. 
 
You asked the Plan to pay for code 99233. You say that You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says code 99233 is not supported by the medical record. 
The records do not support a high level of medical decision making. 
 
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 99233 is  Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found the enrollee was a then 69-year-old male with a history of 
diabetes mellitus, hypertension, and hyperlipidemia who was admitted with acute appendicitis complicated by 
atrial fibrillation. There was no documented medical decision making of high complexity and no total time 
documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service April 13, 2023, to April 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you have a history of disorder of the neck spine (cervical spondylopathy) and prior surgery. There is no documentation of 
osteoarthritis of the hip or knee joints that impairs your ability to perform transfers. There is a normal 
documented musculoskeletal examination. The clinical history is limited regarding your level of function, 
specifically in terms of your ability to walk and perform transfers. The criteria for coverage are not met and the 
seat lift mechanism is not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebroplasty. 
 
You asked the Plan to pre-approve percutaneous vertebroplasty. You say that it is medically necessary. The 
Plan denied your request. The Plan says it is not reasonable and necessary under Medicare guidelines. 
 
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 percutaneous vertebroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation does not corroborate an osteoporotic fracture 
between the T1 through L5 levels. There is no indication of a progression of the body height loss, greater than 
25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is 
magnetic resonance imaging (MRI) corroboration of other plausible causes of pain. Therefore, the enrollee does not meet the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous vertebroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service January 10, 2023. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the medical records 
provided do not include a laboratory order/requisition for the services rendered. A laboratory order/requisition 
of 22 drug classes is required to support the service billed. Based on this information, we decided that Medicare 
rules for coverage of code G0483 have not been met. Therefore, we decided that the Plan does not have to pay 
for code G0483 for date of service January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 1, 2022, billed with 
evaluation and management (EM) coded 99232-GC. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the service at issue was not billed with the 
required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 32853 
provided on June 17, 2022. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
August 1, 2022, billed with evaluation and management (EM) coded 99232-GC.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve the requested services. You say that cognitive testing plays a crucial role in 
the assessment of the enrollee. The Plan denied your request. The Plan says no mental disability is suspected. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a diagnosis of lumbosacral radiculitis. Cognitive testing has been requested 
with regard to prescribing opioids for the enrollee. The provided records in this case do not document any 
history of opioid abuse or any other mental illness/disability. The enrollee is on hydrocodone with no side 
effects and no questions or concerns. As stated in the coverage criteria, testing conducted when no mental 
illness/disability is suspected would be considered screening and would not be covered. Non-specific behaviors 
that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing. 
Therefore, the request 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve neuropsychological testing.