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

 
We decided that the Plan does not have to pay for the services (99220) provided on October 8, 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 99220 is "Initial observation 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 to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital 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 use of code 99220 is 
not supported by the records provided. Our reviewer found that the history is not comprehensive and the 
medical decision-making is not of high complexity. The documentation does not support at least 70 minutes of 
time 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 the services (99220) provided on October 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on January 03, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you are requesting reconsideration for the services 
provided. 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 an x-ray provided on 
January 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rTMS. 
 
You asked the Plan to pre-approve rTMS. You say that rTMS is medically necessary.  The Plan denied your 
request. The Plan says the requested rTMS does not meet the Medicare coverage criteria. The criteria require 
that depression must be resistant to treatment. The Plan says the notes do not show that the enrollee suffers 
from depression that is resistant to treatment. 
 
The Plan follows Medicare rules. Medicare rules say rTMS is covered when the criteria in the Medicare rules 
section of this decision 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 rTMS. Our reviewer says that the 
requested rTMS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on review the records provided this patient had been tried on the following medications: 
imipramine, Zoloft, amitriptyline, Prozac, Wellbutrin while currently taking mirtazapine and Xanax. There is 
no documentation of when the patient took this medication and whether it was during a previous depressive 
episode or current. There is no documentation of the patients refusal for electroconvulsive treatment (ECT). 
Utilizing the Medicare LCD L37088 criteria, it specifically states the confirmation of the diagnosis of severe 
major depressive disorder single or recurrent and one or more of the following, the patient has demonstrated 
resistance to treatment with psychopharmacologic agents as evidenced by lack of clinically significant response 
to for trials of such agents, in the current depressive episode from at least 2 different agent classes or the 
inability to tolerate pharmacologic agents is evidenced by 4 trials of psychopharmacologic agents with distinct 
side effects or history of response to rTMS in a previous depressive episode evidenced by greater than 50 
percent improvement in the standard rating scale or is currently receiving or is a candidate for and has declined 
electroconvulsive therapy and rTMS is considered a less invasive treatment option and a trial of evidence-based 
psychotherapy known to be effective in the treatment of Major Depressive Disorder of an adequate frequency 
and duration without significant improvement in depressive symptoms as documented by standardized rating 
scales. Based on the information provided, this patient does not meet the clinical criteria for the use of rTMS 
therapy as it is unclear when the patient took the medication and at what dose. It is also unclear when the  
PHQ-9 was ordered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rTMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve rTMS.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 77002 rendered on July 14, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the unit of service for this code is the patient encounter, not number of lesions, number of 
aspirations, number of biopsies, number of injections, or number of localizations. 
 
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 77002 is "Fluoroscopic guidance for needle placement 
(eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary 
procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that only one unit of 77002 is allowed 
for a single patient encounter regardless of the number of needle placements performed, therefore this code 
cannot be validated. 
 
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 two units of procedure code 77002 rendered on July 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 17, 2023, to 
January 23, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported appropriately and are sufficiently documented. The Plan denied your 
request. The Plan says the DRG reported on this claim is not supported in the documentation provided, as two 
diagnoses are not supported. 
 
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 gram-negative sepsis, unspecified (A41.50) and 
pneumonia due to other gram-negative bacteria (J15.9). 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 these diagnoses are 
not supported in the records provided. Our physician reviewer found the documentation does not support the 
presence of sepsis or pneumonia due to other gram-negative bacteria. For the former, the patient did not meet 
the criteria for sepsis. For the latter, the patient had pneumonia unspecified, as they did not have positive 
cultures for gram negative bacteria.  
 
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 provided on January 17, 2023, to January 23, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Part B injections provided on April 21, 2023. 
 
You asked the Plan to pay for the Part B injections. You say that the services were medically necessary. 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 Part B injections 
provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 30, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were rendered in a 
nursing home setting. 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 subsequent nursing 
facility care provided on May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connector (E2310). 
 
You asked the Plan to pre-approve the electronic connector. You say that you are appealing on the grounds that 
Medicare has reviewed the request and found the services to be medically necessary and covered under 
Medicare guidelines. The Plan denied your request. The Plan says there is no medical need to control the power 
option through the joystick. 
 
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 electronic connector. Our reviewer says that the requested electronic connector is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation supports that the enrollee has adequate strength to 
manage the power drives. Therefore, the reviewer found that the requested electronic connector is not 
medically reasonable or 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 electronic connector have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connector (E2310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (power scooter) (K0899). 
 
You asked the Plan to pre-approve a power scooter. You say that the patient is unable to operate a manual 
wheelchair. You also say that you would like this request to be reconsidered for approval for the patient's safety 
and independence. The Plan denied your request. The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power scooter. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the documentation available for review 
does not support that the patient requires a power mobility device to accomplish mobility related self-care tasks 
in the home. Our reviewer also found that there is no indication they are unable to use an alternative assistive 
device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power mobility device (power scooter) (K0899).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor. 
 You asked the Plan to pre-approve insertion of a subcutaneous cardiac rhythm monitor. You say that insertion 
of a subcutaneous cardiac rhythm monitor is medically necessary. The Plan denied your request. The Plan says 
insertion of a subcutaneous cardiac rhythm monitor is not medically necessary. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of a subcutaneous cardiac 
rhythm monitor. Our reviewer says that insertion of a subcutaneous cardiac rhythm monitor is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that in the absence of any 
symptoms, syncope, or recent cryptogenic cerebrovascular accident (CVA), the implantable heart rhythm/rate 
recorder is not indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a subcutaneous cardiac rhythm monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm 
monitor.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the IRF admission.  
 
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's 
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. 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 as 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on July 10, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
code for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M are not covered for 
CxBladder testing. 
 
We looked at the file and Medicare rules. Per LCD L35396, the billed code, 0012M, is not covered for 
CxBladder testing. Based on this information, we decided that Medicare rules for coverage of the testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on 
July 10, 2023.
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 enrollee does require an LTACH 
level of care and is stable for discharge to that level of care. You also say that the enrollee clearly meets the 
LTACH criteria, and this request should be approved in order for them to receive the most appropriate care. 
The Plan denied your request. The Plan says the LTACH services requested do not meet the requirements for 
approval. 
 
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 was admitted with respiratory failure and sepsis secondary to pneumonia. 
The enrollee had been intubated but was extubated on November 22, 2023. Our reviewer found since then, the 
enrollee has made significant progress. The enrollee still requires bilevel positive airway pressure (BiPAP) at 
night, had required Precedex until November 21, and still requires intravenous medications for hypertension. 
Our physician reviewer also found that acute care hospitalization has not been completed. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from March 8, 2023, to March 14, 
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 that the Payment Integrity post-service post-
pay clinical validation audit shows that the provider has reported inpatient hospital services with an incorrect 
DRG. 
 
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 diagnosis code A41.9. 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 supported by the medical records. Our physician 
reviewer found that the enrollee had multiple comorbid conditions (diabetes, hyperlipidemia, chronic 
obstructive pulmonary disease), who presented with shortness of breath and altered mental status. While the 
enrollee did not have a sufficient rise in the enrollee's SOFA score, the enrollee did exhibit end-organ 
dysfunction because of the increasing confusion/altered mental status. The enrollee had a high fever, 
tachycardia tachypnea, leukocytosis, oxygen desaturation. This enrollee meets sepsis criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services rendered from March 8, 2023, to March 14, 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.