Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous imaged-guided lumbar decompression 
(PILD) procedure (0275T). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not show imaging findings to support the diagnosis of lumbar 
spinal stenosis. No computed tomography scan or magnetic resonance imaging scan of your lumbar spine has 
been performed and your plain films are supportive of other diagnoses such as facet arthropathy. It is unclear 
that you have symptoms of neurogenic claudication. 
 
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 services. Our reviewer says that the 
requested items/services are 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 
request to be an effective and/or safe treatment for the noted pathology. Overall, the peer-reviewed literature 
finds only modest evidence for efficacy. Further studies are needed to prove the efficacy of this treatment over 
the gold standard surgical procedures. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested percutaneous 
imaged-guided lumbar decompression (PILD) 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous imaged-guided lumbar decompression (PILD) procedure (0275T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 27, 
2023.  
 
You asked the Plan to pay for procedure code 86077. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
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 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 rendered on April 21, 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 Current Procedural Terminology (CPT) code 99204 (1 Unit ) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level or that 45 
minutes were spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99204 rendered on April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 12, 2023. 
 
You asked the Plan to pay for the lab services. You say that Medicare covers this testing. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services provided on April 12, 
2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition to an endoskeletal knee-shin system, stance flexion 
feature, adjustable (L5845). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are reasonable and 
necessary, and there is sufficient documentation of functional need. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no doubt that, based on the original exam and medical record presented, that the entire 
requested prosthesis, including the still denied L5845, would be considered reasonable and necessary. Lesser 
devices would not meet the enrollee's functional needs, and would amount to substandard care. This would be 
considered standard care for the enrollee. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve an addition to an endoskeletal knee-shin system, stance flexion feature, adjustable (L5845).  
 
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.
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 intensive inpatient rehabilitation 
with daily physician management, continuous specialized rehabilitation nursing, and intensive therapies to 
optimize mobility and strengthening while ensuring the restoration of functional status. The Plan denied your 
request. The Plan says the criteria for admission to an IRF setting have not been met.  
 
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 rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement. However, the documentation does not support that they would meet criteria for 
admission to an IRF.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain their functional status.  The enrollee can receive further services at a lower 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 12, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you disagree with 
the copayment applied for the ER visit. 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 $100 
copayment for emergency care. 
 
You have been asked to pay a $100 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency care 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 an 
emergency room (ER) visit provided on May 12, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for intraperitoneal procedures in upper abdomen (00790) 
provided on June 27, 2023. 
 
You asked the Plan to pay for anesthesia for intraperitoneal procedures in upper abdomen (00790). You say 
that the claim is billed correctly and should be reconsidered. The Plan denied your request. The Plan says that 
the records do not support the number of units billed. 
 
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 00790 is anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise 
specified. 
 
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 anesthesia for intraperitoneal procedures in upper abdomen 
(00790). Our reviewer says that the documentation supports 141 units for the anesthesia services performed 
under procedure code 00790.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia for intraperitoneal procedures in upper abdomen (00790) have been 
met. Therefore, we decided that the Plan has to pay for anesthesia for intraperitoneal procedures in upper 
abdomen (00790) provided on June 27, 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29540 billed for date of service July 3, 2023.  
 
You asked the Plan to pay for procedure code 29540. You say that the enrollee was diagnosed with plantar 
fasciitis bilaterally and the strapping is used to hold the arch in position of optimal function. You say that this is 
a separate identifiable service, and the code should be reconsidered for payment. The Plan denied your request. 
The Plan says the number of units billed exceeds the maximum allowed.  
 
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 29540 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29540 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29540 billed for date of service July 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy, surgical; urethral suspension for stress 
incontinence (51990), and nerve repair; with synthetic conduit or vein allograft, each nerve (64910). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a review of the current medical literature indicates urethral suspension is not a procedure 
routinely performed in association with radical prostatectomy. One study found some improvement in short 
term incontinence with concomitant urethral suspension, but no improvement in long term continence. National Comprehensive Cancer Network (NCCN) discussion of principles of surgery list strategies to reduce urinary 
incontinence; performance of urethral suspension at the time of surgery is not one of them. Similarly, nerve 
grafting is not a routinely performed procedure in association with radical prostatectomy. NCCN guidelines 
state replacement of resected nerves with nerve grafts has not been shown to be beneficial. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laparoscopy, surgical; urethral suspension for stress incontinence (51990), and nerve 
repair; with synthetic conduit or vein allograft, each nerve (64910).
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 current rehabilitation center does not provide the 
level of care that the enrollee's surgeon says is needed for a full recovery. The Plan denied your request. The 
Plan says the enrollee's needs can be met at a lower level of care 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 On review of the available records, the enrollee has a  history of right hip fracture, 
and is status post surgery. The enrollee is medically stable and does not need medical monitoring by a 
physician with close supervision for the conditions described above 3 times per week (at a minimum). The 
enrollee needs continued physical therapy and occupational therapy (PT and OT) and does not need 3 hours a 
day x 5 days a week of therapies with multidisciplinary approach in an IRF. The documentation does not 
support medical necessity for admission to an IRF. The enrollee has no medical complexity currently with no 
acute rehab nursing needs to warrant an admission to an IRF. While the enrollee would benefit from PT and 
OT 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: 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 is at a high-risk for falling, and is in 
need of physical therapy and occupational therapy. The Plan denied your request. The Plan says the enrollee's 
needs can be met at a lower level of care 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 that the enrollee is medically stable and does not need physicians supervision 3 
times a week in an IRF. There are no acute rehab nursing needs documented. At the current functional level, 
the enrollee is unlikely to make a significant functional progress in 7-10 days as predicted in the preadmission 
screening for IRF. The enrollee needs routine physical and occupational therapy (PT and OT) and does not 
need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. The record does not support necessity for admission to an IRF. The 
complexity of the enrollees medical, rehab, and nursing needs (combined complexity) does not require 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dual chamber pacemaker. 
 
You asked the Plan to pre-approve a dual chamber pacemaker. You say that a dual chamber pacemaker is 
medically necessary. The Plan denied your request. The Plan says no clinical documentation supports the need 
for implantable permanent pacemaker in general. 
 The Plan follows Medicare rules. Medicare rules say that a dual chamber pacemaker is covered when the 
criteria listed 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 a dual chamber pacemaker. Our 
reviewer says that the requested dual chamber pacemaker is not considered medically reasonable and necessary 
in this case. Our physician reviewer found while the enrollee has a history of bradycardia, there is no 
documentation of symptomatic bradycardia. As such, there is insufficient documentation to support the medical 
necessity for insertion of a pacemaker in this enrollees 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 a dual chamber pacemaker have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a dual chamber pacemaker.