Persius/hicric huggingface dataset:
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 you need intense physical therapy to regain 
maximum function. The Plan denied your request. The Plan says you do 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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that you would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain your functional status.  You 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 billed for date of service March 21, 
2023.  
 
You asked the Plan to pay for procedure code 99309. You say that the claim is billed correctly and should be 
paid. 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 99309 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 99309 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99309 billed for date of service March 21, 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 services are medically necessary for the enrollee 
to receive the daily services needed to reach their goals and ensure a safe return home. 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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement. However, the documentation doesnt support that they 
would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF 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: 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 based on the enrollee's current physical and 
occupational deficits as well as their comorbidities, the enrollee requires and would benefit from intensive 
inpatient rehabilitation with daily physician visits and examinations, continuous rehabilitation nursing care, and 
intensive therapies to optimize mobility and regain the ability to perform their activities of daily living. The 
Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 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. 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 
member 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: 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 services are medically necessary. 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 document does not support necessity for admission to an IRF. The complexity of the 
enrollees medical, rehab, and nursing needs does not require an 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 an 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and accessories (K0861, E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, 
and K0108). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and accessories. 
You say that the requested group 3 power wheelchair with multiple power options is medically necessary.  The 
Plan denied your request. The Plan says the enrollee does not meet criteria for a group 3 power wheelchair with 
multiple power options.  
 
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 a group 3 power wheelchair with 
multiple power options and accessories. Our reviewer says that the enrollee does not meet criteria for a group 3 
power wheelchair with multiple power options. Our physician reviewer found the enrollee has muscular 
dystrophy and left hemiplegia. She is noted to not be at high risk for skin breakdown, she's able to 
independently manage a joystick and does not have spasticity. Per Medicare criteria the enrollee does not 
require tilt or tilt and recline. She does not have high risk for skin breakdown, use a catheter intermittently, 
have spasticity or require an alternative means of managing power drive. 
 
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 group 3 power wheelchair with multiple power options and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options and accessories (K0861, E0955, E1007, E1012, E1028, E2311, E2313, E2361, 
E2377, E2607, E2620, and K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye refractions (92015) provided on May 31, 2023. 
 
You asked the Plan to pay for the eye refractions. You say that this service was medically necessary and should 
be covered. The Plan denied your request. The Plan says routine eye refractions are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for eye refractions (92015) provided on May 31, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
26, 2023, billed with code 99285. 
 
You asked the Plan to pay for the ED services as billed. You say that this ED encounter was billed correctly. 
The Plan denied your request. The Plan says the records do not support code 99285. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 ED services as billed. Our reviewer says 
that the reported CPT code is not supported by the medical records. Our reviewer found the enrollee has a 
history of chronic obstructive pulmonary disease and chronic low blood pressure. He presented with low blood 
pressure and dizziness. At the time of presentation, the enrollee was asymptomatic. He did have a workup which was mostly unremarkable. He was treated with a liter of saline for mild dehydration. 
 
Per the documentation, the enrollee did not have a limb or life-threatening condition or require critical or 
extensive care. Mild dehydration was a minor problem. Therefore, the documentation does not support medical 
decision making of high complexity. 
 
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 ED services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department (ED) services provided on June 26, 2023, billed with code 
99285.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 
87581, 87640, 87651 and 87798 billed for March 7, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651 and 
87798 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 87486 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia pneumoniae, amplified probe technique. The definition of code 87496 is infectious agent 
detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique. The definition of code 
87498 is infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed. The definition of code 87502 is infectious agent detection by 
nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse 
transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types. The 
definition of code 87532 is infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, 
amplified probe technique. The definition of code 86541 is infectious agent detection by nucleic acid (DNA or 
RNA); Legionella pneumophila, amplified probe technique. The definition of code 87581 is infectious agent 
detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique. The definition 
of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified 
probe technique. The definition of code 87651 is infectious agent detection by nucleic acid (DNA or RNA); 
Streptococcus, group A, amplified probe technique. 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 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651 and 87798 are not 
supported in the medical record. Specifically, the records show that a panel was performed and there is a more 
appropriate single code for the services. 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 pay for 
procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651 and 87798 billed for March 
7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BRCA genetic testing rendered on May 8, 2023. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA testing 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 pay for these services. Our reviewer says that the 
criteria for coverage are not met. Our physician reviewer found the records do not support that the enrollee has 
been diagnosed with breast, ovarian, or pancreatic cancer. The records do not support that the BRCA testing 
meets the criteria for coverage and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the BRCA genetic testing rendered on May 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for codes 22612, 20936, 22614, 63047, 63048, 72082, 76000, 
82565, 83735, 83880, 84132, 84295, 85027, 86850, 86900, 86901, 94664, 95925, 95940, 97161, 97165, 97535, 
97535, J1100, J1170, J2250, J2370, J2405, J2710, and J3010 for date of service May 5, 2023, to May 8, 2023. 
 
You asked the Plan to pay for codes 22612, 20936, 22614, 63047, 63048, 72082, 76000, 82565, 83735, 83880, 
84132, 84295, 85027, 86850, 86900, 86901, 94664, 95925, 95940, 97161, 97165, 97535, 97535, J1100, J1170, 
J2250, J2370, J2405, J2710, and J3010. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of a device-intensive procedure 
also requires that a device be submitted on the same claim/day. 
 
We looked at the file and Medicare rules. Review of the file shows that code 22612 identifies as a device 
dependent code. This means that an applicable device code must be billed with it. Review of the other 
procedure codes (20936, 22614, 63047, 63048, 72082, 76000, 82565, 83735, 83880, 84132, 84295, 
85027, 86850, 86900, 86901, 94664, 95925, 95940, 97161, 97165, 97535, 97535, J1100, J1170, J2250, 
J2370, J2405, J2710 and J3010) billed on the claim are not valid device codes. As there was no applicable 
device code billed on the claim, the claim cannot be paid as billed. Based on this information, we decided that 
Medicare rules for coverage of codes 22612, 20936, 22614, 63047, 63048, 72082, 76000, 82565, 83735, 
83880, 84132, 84295, 85027, 86850, 86900, 86901, 94664, 95925, 95940, 97161, 97165, 97535, 97535, J1100, 
J1170, J2250, J2370, J2405, J2710, and J3010 have not been met. Therefore, we decided that the Plan does not 
have to pay for codes 22612, 20936, 22614, 63047, 63048, 72082, 76000, 82565, 83735, 83880, 84132, 84295, 
85027, 86850, 86900, 86901, 94664, 95925, 95940, 97161, 97165, 97535, 97535, J1100, J1170, J2250, J2370, 
J2405, J2710, and J3010 for date of service May 5, 2023, to May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided May 19, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of coverage for 
the Cxbladder Detect test for the enrollee. The Plan denied your request. The Plan says the Cxbladder panel 
remains unproven at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder Detect test (0012M) provided May 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code B4103 for date of service April 20, 2023. 
 
You asked the Plan to pay for code B4103. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are inconsistent with the enrollee's age. 
 
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 B4103 is enteral formula, for pediatrics, used to replace 
fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit. 
 
We find that CPT code B4103 is not supported in the medical record. Specifically, code B4103 is a pediatric 
code, which is used for children under the age of 18. Review of the file shows that the enrollee is over the age 
of 18. Based on this information, we decided that Medicare rules for coverage of code B4103 have not been met. Therefore, we decided that the Plan does not have to pay for code B4103 for date of service April 20, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27059 billed for date of service June 27, 
2023. You asked the Plan to pay for procedure code 27059. You say that this procedure does not require an anatomic 
modifier and was billed appropriately without one. The Plan denied your request. The Plan says this claim must 
be resubmitted with an anatomic modifier for code 27059. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 27059 have not been met. Specifically, procedure code 27059 has a bilateral 
surgery indicator of 1, meaning that the use of an RT, LT or bilateral (50) modifier applies. An anatomical 
modifier is necessary to clarify if this service was performed bilaterally or on one side. Therefore, we decided 
that the Plan does not have to pay for procedure code 27059 billed for date of service June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute rehabilitation facility to be provided by an out-
of-network (OON) provider/facility.  
 
You asked the Plan to pre-approve an acute rehabilitation facility. You say that participating in inpatient 
rehabilitation will allow you to gain strength and endurance. You do not want to have any further injuries, such 
as a fall, that will ultimately prevent another acute hospitalization. The Plan denied your request. The Plan says 
you have been authorized and admitted to an in-network acute rehabilitation facility. You must use network 
providers/facilities to get your medical care and services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider/facility in this case is not a network provider/facility with the Plan. The Plan has 
network providers/facilities available who can provide the items/services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan 
does not have to pre-approve an acute rehabilitation facility to be provided by an out-of-network (OON) 
provider/facility.