Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation system. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific criteria. 
 
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 high frequency chest wall oscillation 
system. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not meet criteria for HFCWO device nor has the LCD indications. 
 
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 high frequency chest wall oscillation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says when the enrollee is ready to leave the hospital, they 
can receive this care in another setting such as a skilled nursing facility (SNF). 
 
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 stable on oxygen and bilevel positive airway pressure (BiPap) support 
which is equivalent to what they have used at home and is receiving routine dialysis. The enrollee doesn't 
appear to have any care needs that can only be furnished at another facility. In addition, it doesn't appear that the enrollee's inpatient care needs will meet or exceed an additional 25 days. 
 
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on December 20, 2022. 
 
You asked the Plan to pay for the air ambulance services. You say that the transport method was medically 
necessary. The Plan denied your request. The Plan says there was no clear barrier to transport to the closest 
appropriate facility or use of ground transportation. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found the enrollee could have been 
safely transported by the ground ambulance to a closer hospital for an initial evaluation, before deciding if 
transfer 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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 15, 2022, to July 23, 
2022, billed with procedure codes 99223 and 99232. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is billed correctly and should be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of codes 99223 and 99232 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, and Subsequent hospital care, per day, for the evaluation and management of a patient, which requires 
at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem 
focused examination; Medical decision making of moderate 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 patient is responding 
inadequately to therapy or has developed a minor complication. Typically, 25 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the medical record does not include a 
procedure report to support initial hospital care report was performed. Although the medical record includes 
hospital visits during billing dates of service, an initial hospital care note was not found, therefore the course of 
this hospital stay cannot be verified. As such, the billed codes cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 15, 2022, to July 23, 2022, billed with 
procedure codes 99223 and 99232.
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 IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for admission to 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 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, and there are no complex nursing or rehabilitation needs. Medically necessary 
services can be provided in 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 increase the reimbursement the walker on June 15, 2023.  
 
You asked the Plan to increase the reimbursement the walker. You say that you were told you would be 
reimbursed 80% and your responsibility would be 20% for in-network provider. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance at a durable medical equipment provider.  
 
 
 
 You have been asked to pay a 20% coinsurance for the walker. This item/service falls within the durable 
medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to increase the 
reimbursement the walker on June 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye procedure (92250) 
provided on August 28, 2023. 
 
You asked the Plan to waive the copayment for a diagnostic eye procedure (92250). You say that the services 
should be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Outpatient diagnostic tests and therapeuticservices and supplies. 
 
You have been asked to pay a $50 copayment for a diagnostic eye procedure (92250). This item/service falls 
within the Outpatient diagnostic tests and therapeuticservices and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a diagnostic eye procedure (92250) provided on August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown 
(D6058) for teeth #18 and #31. 
 
You asked the Plan to pre-approve D6058. You say that this should be covered. The Plan denied your request. 
The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers D6058 when 
the services are medically necessary and reasonable.  
 
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 D6058. Our reviewer says that this 
dental work is not medically necessary. Our physician reviewer found there are no periapical x-rays that show 
the implants that show the full amount of bone around the implants. The bitewing x-rays only show part of the dental implants. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D6058 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an abutment supported porcelain/ceramic crown (D6058) for teeth #18 and #31.
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 denial of medical coverage to the IRF will seriously 
jeopardize the enrollee's life, health, and rehabilitation. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for an 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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute 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, 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 program provided in an IRF. 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: 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 chronic low back pain 
and would benefit from this procedure. The Plan denied your request. The Plan says this procedure is 
considered experimental. 
 
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. The cause of pain is also 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has multiple complex 
medical issues that cannot be managed at a lower level of care and will need ongoing daily physician 
management. You also say skilled nursing facilities do not offer the close monitoring and available 
interventions that an LTACH offers. The Plan denied your request. The Plan says admission to an LTACH is 
not medically necessary.  
 
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 that there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous.  
 
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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36222 and 36225 billed for date of service 
March 2, 2023. 
 
You asked the Plan to pay for procedure codes 36222 and 36225. You say that all codes billed on the claim 
were performed and modifier 59 was attached to each eligible code. You say that all codes should be processed 
and paid separately. The Plan denied your request. The Plan says payment for codes 36222 and 36225 is 
included in payment for other services performed on the same date of service. 
 
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 36222 is a column II code to column I code 36223, and code 36225 is 
a column II code to column I code 36226; however, 36222 and 36225 were billed with a modifier.  
 
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 procedure codes 36222 and 36225. Our reviewer says that 
procedure codes 36222 and 36225 do not meet the criteria for coverage. Our reviewer found the procedure 
report does not include documentation to support separate payment rationale for procedure codes 36222 and 
36225. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 36222 and 36225 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 36222 and 36225 billed for date of service March 2, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided on March 30, 2023,
billed with procedure code 99153.

You asked the Plan to pay for code 99153. The Plan denied your request. The Plan says the Medicare billing
criteria were not met.

The Plan is correct in this case. The Plan follows Medicare rules. Medicare rules say that code 99153 is a "PE"
only code and is not payable to the physician for services provided in the facility setting. As there is no separate
payment to the physician for code 99153 when performed in the facility setting, this claim was submitted in
error. Therefore, we decided that the Plan does not have to pay for code 99153 provided on March 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal fusion surgery and i-Factor allograft. 
 
You asked the Plan to pre-approve the i-Factor allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of i-Factor allograft in the setting of 
lumbar spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 i-Factor allograft. Our reviewer says 
that the requested i-Factor allograft is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the reviewer found that the requested i-Factor allograft 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 i-Factor allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal fusion surgery and i-Factor allograft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Minuteman interspinous device. 
 
You asked the Plan to pre-approve the Minuteman device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of the Minuteman 
interspinous device in the setting of lumbar stenosis has not been demonstrated in the peer-reviewed literature. 
 
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 Minuteman device. Our reviewer 
says that the requested Minuteman device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Minuteman device is experimental. More research is needed to show safety 
and efficacy. Therefore, the reviewer found that the requested Minuteman device 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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a Minuteman interspinous device.