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

 
We decided that the Plan does not have to pay for the evaluation and management (E&M) services described 
by code 99308-25 performed on date of service July 20, 2023. 
 
You asked the Plan to pay for 99308-25. You say that 99308-25 was a significant and separately identifiable 
E&M service unrelated to the decision to perform the minor surgical procedure, and was billed with modifier -
25, therefore it should be paid as billed. The Plan denied your request. The Plan says 99308-25 is denied 
because it was billed on the same date as a minor procedure and documentation does not support a significant 
and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure. 
 
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 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 99308-25. Our reviewer says that 99308-25 is not supported in the documentation. Our reviewer found the medical record documents that the enrollee was seen for wound 
care and debridement was performed. The medical record documents "Procedure: Surgical excisional 
debridement was performed today on this wound." In this case, a significant, identifiable evaluation and 
management service was not found in medical record. When a significant and separately identifiable E&M 
service and a procedure are both performed, the documentation of the encounter must clearly reflect two 
separate services with no overlap in work between the E&M service and the procedure. The documentation 
must explain what work was associated with the E&M service and separately explain what work was 
associated with the procedure, with a clear distinction that there was no overlap between the two. The medical 
record in this case does not support this. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99308-25 have not been met. Therefore, we decided that the Plan does not have 
to pay for the evaluation and management (E&M) services described by code 99308-25 performed on date of 
service July 20, 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 prior to this hospital admission the enrollee was 
functionally independent at home and needs this inpatient rehabilitation to return to the prior level of 
functioning in a short period of time. The Plan denied your request. The Plan says the enrollee's condition does 
not meet all the requirements for inpatient rehabilitation admission. The Plan says services may be provided at 
a lower level of care.  
 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 medical 
records support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It 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.  
 
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 pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was admitted with chronic 
obstructive pulmonary disease (COPD) exacerbation and multi-lobar pneumonia that was treated with 
appropriate therapy, including bi-level positive airway pressure (BiPAP) with average volume-assured pressure 
support (AVAPS). He tolerated the intervention with improvement, per the records. There is no indication for a 
home ventilator at this time and the services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that TTFT is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a glioblastoma 
multiforme (GBM) treated with external beam radiation therapy (EBRT) and temozolomide. Scans show 
progression of disease and plan is to continue temozolomide with the addition of Optune TTFT. The enrollee 
did not receive primary setting and Optune TTFT is not being used as first line therapy. The criteria for 
coverage are not met and the TTFT is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tumor treatment field therapy (TTFT).
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 would like to regain their strength to be 
able to be independent and a chance to return to their home. The Plan denied your request. The Plan says the 
inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval.  
 
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 
was admitted for lumbar spine surgery. 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. Medically necessary care can be provided in a 
different level of care. 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.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is only readily suspected of 
having AD. There is no indication of a suspicion for both AD and FTD, nor does the enrollee meet diagnostic 
criteria for both conditions. In as much, the base requirements of the NCD for coverage of this service would 
not be met at this time. Therefore, this service would not be eligible for coverage.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. Although this enrollee takes Glipizide that can cause lows blood 
sugars, we are not told of any problematic low blood sugars that the enrollee has. Although a CGM may help 
the enrollee, the coverage criteria are not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
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 meets Medicare criteria for admission to 
an IRF. 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 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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 84443 and 84439. We 
decided that the Plan does not have to pay for the services described by procedure code 84436.  
 
You asked the Plan to pay for the lab services described by codes 84436, 84443, and 84439 billed on date of 
service December 27, 2022. You say that 84436, 84443, and 84439 should be paid as billed because they are 
supported in the documentation. The Plan says that 84436 is denied because payment for this service is bundled 
into payment for 84439. 84443 and 84439 have received new denials under another claim. 
 
We decided that the Plan has to pay for the services described by procedure codes 84443 and 84439.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide any information regarding their appeal 
decision for the codes listed in this section. As the Plan forfeited its opportunity to provide a denial rationale 
for these services, we find that the denial of payment is not supported. Therefore, we decided that the Plan has 
to pay for the services described by procedure codes 84443 and 84439.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 84436. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
We looked the file and Medicare rules. In this case, we have confirmed that code 84436 is a column two code 
to column one code 84439 with a modifier indicator of 0. The column two code is therefore not payable. Based 
on the claim submitted, Medicare billing criteria have not been met. Based on this information, we decided that 
Medicare rules for coverage of the services described by procedure code 84436 have not been met. Therefore, 
we decided that the Plan does not have to pay for the services described by procedure code 84436. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
  You asked the Plan to pre-approve a home ventilator. You say that you are ordering non-invasive ventilation 
(NIV) with average volume-assured pressure support (AVAPS) auto-expiratory positive airway pressure to 
better manage the patient's carbon dioxide (CO2) retention and provide respiratory support for exertional 
distress in the daytime. You also say that you are urgently asking for the patient's insurance to review an appeal 
to grant authorization for this much needed therapy. The Plan denied your request. The Plan says this request 
for a home mechanical ventilator set in AVAPS mode with auto-expiratory positive airway pressure that could 
be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has COPD and 
heart failure with preserved ejection fraction. The patient has had multiple hospitalizations for COPD 
exacerbations. An arterial blood gas (ABG) on November 6, 2023, was consistent with mild chronic 
hypercarbic respiratory failure. Our reviewer found that another ABG on November 20, 2023, at the time of 
hospital readmission, showed a normal partial pressure of carbon dioxide of 36 while on BiPAP with pressures 
of 12/6. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. This patient may benefit 
from BiPAP with AVAPS during sleep as an outpatient. Our physician reviewer also found that the records do 
not show this has been tried and failed as an outpatient.  Medicare does not cover a home ventilator when used 
at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements have not been met. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding imaging or radiographic evidence supporting a 
sacroiliitis pathology. Multiple other plausible pain generators including at the lumbosacral spine are evident. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested sacroiliac joint fusion 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 sacroiliac joint fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 3, 2023, billed with 
procedure code 99213-25. 
 
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. 
 
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 procedure report describes wound 
assessment and treatment. A significant, separately identifiable evaluation and management service was not 
documented in the report and therefore 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 July 3, 2023, billed with procedure code 
99213-25.