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

 
We decided that the Plan has to pre-approve a endoskeletal knee-shin system, stance flexion feature (L5845). 
 
You asked the Plan to pre-approve a endoskeletal knee-shin system, stance flexion feature. You say that the 
item is medically necessary. The Plan denied your request. The Plan says that this component is already 
included in the approved knee. 
 
The Plan follows Medicare rules. Medicare rules say that 5925, L5930, L5845, L5848, L5850, L5856, L5857, 
L5858, L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin 
system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5616, 
L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840).  
 
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 endoskeletal knee-shin system, stance 
flexion feature. Our reviewer says that the item is medically necessary. Our physician reviewer found the item 
is not included in the approved components. 
 
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 endoskeletal knee-shin system, stance flexion feature have been met. 
Therefore, we decided that the Plan has to pre-approve a endoskeletal knee-shin system, stance flexion feature 
(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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
May 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for diabetes problems. The 
Plan denied your request. The Plan says the billed codes 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. 
 
We find that outpatient intravenous insulin therapy, billed with CPT codes 96365 and 96366 are not supported. 
There is a more accurate code that describes the services provided. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 96365 and 96366 billed for date of service May 17, 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 needs the services to regain 
maximum or prior level of functioning. The Plan denied your request. The Plan says these services are 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 a transfer to the LTACH would not be clinically advantageous at this time. The 
enrollee does not require services at the LTACH that are not already available at the current facility. 
Completion of treatment at the current facility is recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is 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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 22, 2023, billed 
with procedure code 99239. 
 
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 documentation does not support the billed code. 
 
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 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical records do not include 
sufficient documentation to support total time spent providing service to the enrollee on February 22, 2023, 
therefore this service 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 February 22, 2023, billed with procedure 
code 99239.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (38724, 60260, 60500, 80048, 80053, 
82330, 82962, 83735, 83970, 84100, 84132, 85027, 86850, 86900, 86901, 88305, 88307, 95865, 95937, 95955, 
G0257, J0171, J0690, J1170, J2370, J2405, J3010) provided on January 26, 2023 to January 27, 2023. 
 
You asked the Plan to pay for the outpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT codes 38724, 60260, 60500, 80048, 80053, 82330, 82962, 83735, 83970, 84100, 84132, 
85027, 86850, 86900, 86901, 88305, 88307, 95865, 95937, 95955, G0257, J0171, J0690, J1170, J2370, J2405, 
& J3010 are not supported in the medical record. Specifically procedure code 38724 is an inpatient only procedure. The claim was billed with an outpatient type of bill. The remaining services were provided on the 
same day as part of the primary procedure. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay 
for outpatient services (38724, 60260, 60500, 80048, 80053, 82330, 82962, 83735, 83970, 84100, 84132, 
85027, 86850, 86900, 86901, 88305, 88307, 95865, 95937, 95955, G0257, J0171, J0690, J1170, J2370, J2405, 
J3010) provided on January 26, 2023 to January 27, 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 the enrollee requires intense inpatient rehab for their 
complex medical needs. 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 procedure codes 83520 and 87798 billed for date of service 
December 13, 2022. 
 
You asked the Plan to pay for the billed services. You say that the specimens were processed without delay. 
The Plan denied your request. The Plan says the billed codes 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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. We find that CPT codes 83520 and 87798 are not supported in the medical record. The records show that a 
comprehensive panel and multiple stool tests were provide. The claim does not identify which tests these 
unspecified codes are associated with. Based on this information, we decided that Medicare rules for coverage 
of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 83520 and 87798 billed for date of service December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tennis club membership provided on January 1, 2023. 
 
You asked the Plan to pay for the tennis club membership . You say that you have been receiving a 
reimbursement for the tennis club for years. You say this is a legitimate club. The Plan denied your request. 
The Plan says the service is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only a qualified health club or fitness facility. 
 The Plans rules for coverage of gym benefits have not been met because the tennis club membership is not a 
qualified health club or fitness facility. Therefore, we decided that the Plan does not have to pay for the tennis 
club membership provided on January 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the enrollee is in severe pain and has trouble 
moving. The Plan denied your request. The Plan says there is insufficient documentation of reevaluation after a 
trial of non-surgical management. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty may be covered if certain criteria 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 Kyphoplasty. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee does not meet the critera for 
kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G2212 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the services billed. 
The Plan denied your request. The Plan says the documentation does not support this code. 
 
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 G2212 is prolonged office or other outpatient evaluation 
and management service(s) beyond the maximum required time of the primary procedure which has been 
selected using total time on the date of the primary service; each additional 15 minutes by the physician or 
qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 
99205, 99215, 99483 for office or other outpatient evaluation and management services) (do not report g2212 
on the same date of service as 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 
15 minutes). 
 
We find that CPT code G2212 is not supported in the medical record. The claim shows that CPT code 99214 
was also billed on this date of service, which indicates 30-39 minutes of total time spent. The records show that 
45 minutes was spent with the enrollee. Code G2212 should not be reported for any time unit less than 15 
minutes. Furthermore, code G2212 was not billed with an appropriate primary procedure code. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code G2212 billed for date of service July 19, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that that the enrollee does not meet admission requirements. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found this enrollees condition is complex and fragile, but the Plan made no specific, relevant objections to 
why the enrollee was not yet ready for IRF admission on August 31. Since the enrollee's transfer to the IRF, 
documentation suggests that the enrollee is participating in and benefitting from services such as physical 
therapy, occupational therapy, and physician oversight of polypharmacy. When the enrollee is ready for 
discharge, the enrollee will also benefit from case manager coordination of any additional services that might 
be needed to make a sustainable return home. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0425, A0429) provided on 
October 25, 2022. 
 
You asked the Plan to pay for the ambulance transportation. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance services are separately reimbursable 
only under Part B. Once a beneficiary is admitted to a hospital or skilled nursing facility, it may be necessary to 
transport the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary 
maintains inpatient status with the original provider. This movement of the patient is considered "patient 
transportation" and is covered as an inpatient hospital service. 
 We looked at the file and Medicare rules. The patient was an inpatient at the time this service was rendered. 
This service is included in the inpatient payment. Based on this information, we decided that Medicare rules for 
coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have 
to pay for ambulance transportation (A0425, A0429) provided on October 25, 2022.
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 inpatient rehabilitation is both physically and 
medically necessary for the enrollee to return home at maximum level of functioning with decreased risk for 
readmission. The Plan denied your request. The Plan says the enrollee does not meet the requirements 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 27, 2023, to March 
28, 2023, billed with evaluation and management (EM) code 99223-AI. 
 
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 documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital 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. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 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 code. Our reviewer found that the medical records provided does not 
include sufficient documentation to validate that CPT 99223 was performed on March 27, 2023, therefore this 
procedure 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 March 27, 2023, to March 28, 2023, billed 
with evaluation and management (EM) code 99223-AI.