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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for admission to an SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cogenex Amniotic Membrane (Q4229). 
 
You asked the Plan to pre-approve Cogenex Amniotic Membrane. 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 Cogenex Amniotic Membrane. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is not a standard of care for treatment of wounds after removal of basal 
cell carcinoma. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cogenex Amniotic Membrane have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Cogenex Amniotic Membrane (Q4229).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 47562-80 billed for date of service February 
10, 2023. 
 
You asked the Plan to pay for procedure code 47562-80. You say that this service was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this service was not billed with 
an appropriate modifier for the type of provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that physician assistant-at-surgery 
services are billed with modifiers -80, -81 or -82. Physician assistants, nurse practitioners and clinical nurse specialists use modifier -AS. 
 
We find that CPT code 47562-80 is not supported in the medical record. Specifically, the rendering provider in 
this case is a physician assistant, not a physician. This means the -AS modifier should be used, rather than -80. 
Based on this information, we decided that Medicare rules for coverage of procedure code 47562-80 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 47562-80 billed for date 
of service February 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way and air mileage provided on November 11, 2021. 
 You asked the Plan to pay for the air ambulance services and air mileage. You say that based on clinical 
documentation during patient transport and a registered nurse who has multiple years of critical care field 
experience, believes this transport meets medical necessity guidelines. The Plan denied your request. The Plan 
says after reassessing the entire clinical situation, the information provided at the time of the appeal does not 
support criteria for air ambulance transport. There were multiple closer facilities with appropriate services to 
treat the enrollee. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the air ambulance services and air mileage. 
Our reviewer says that the air ambulance transport services were not medically necessary. Our physician 
reviewer found the enrollee was evaluated for altered mental status. Initial work-up was concerning for sepsis 
and pneumonia. It is unclear why the sending facility could not treat the enrollee. Assuming a high level of care 
was required, it is unclear why the receiving facility was selected for transfer. There is no evidence that other 
closer facilities were inappropriate for the enrollee or otherwise unable to accommodate them. The air transport 
to a more distant facility is not shown to be medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the air ambulance services and air mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one way 
and air mileage provided on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 billed for date of service February 9, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the services were necessary to assist the 
physician. The Plan denied your request. The Plan says the coding is 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 87900 is infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. We find that CPT code 87900 is not supported in 
the medical record. 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 code 87900 
billed for date of service February 9, 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 without this level of care and treatment, 
it will take longer for the enrollee to bounce back and heal, as they have attempted a skilled nursing facility and 
failed. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found the enrollee appears to be improving and should only require short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous at this time and 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (52005 and 44005) provided on 
February 1, 2023. 
 
You asked the Plan to pay for surgical assistant services. You say that these services were necessary and were 
performed by an eligible provider. The Plan denied your request. The Plan says a surgical assistant is not 
necessary or permitted for code 52005, and the payment for code 44005 is included in the payment for code 
50543 reported on the same claim. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 52005. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid.  
 
In addition, Medicare rules say that providers must report services correctly. Providers must report services 
with the appropriate CPT code. In this case, we have confirmed that code 44005 is a column II code to column 
I code 50543 with a modifier indicator of 0. The column II code is therefore not payable. Based upon this 
information, we find that Medicare coverage criteria for surgical assistant services have not been met. 
Therefore, we decided that the Plan does not have to pay for surgical assistant services (52005 and 44005) 
provided on February 1, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93880, defined as a duplex scan of extracranial arteries; 
complete bilateral study, and code 93925, defined as duplex scan of lower extremity arteries or arterial bypass 
grafts; complete bilateral study, performed on February 20, 2023. 
 
You asked the Plan to pay for ultrasound services coded as 93880 and 93925. You say that ultrasound services 
coded as 93880 and 93925 should be paid as billed because they are supported in the documentation. The Plan 
denied your request. The Plan says ultrasound services coded as 93880 and 93925 are not eligible for 
reimbursement because they are not supported in the documentation.  
 
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 93880 is duplex scan of extracranial arteries; complete 
bilateral study. The CPT Code Manual definition of code 93925 is duplex scan of lower extremity arteries or 
arterial bypass grafts; complete bilateral study. 
 
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 ultrasound services coded as 93880 and 93925. Our reviewer 
says that code 93880 is not supported in the documentation and code 93925 is not supported in the 
documentation. Our reviewer found that in reference to 93880, the procedure report does not support a 
complete bilateral study. There is a more appropriate code to report for service documented. To bill for a 
limited duplex scan, the dictation must at least include color and spectral doppler; to billed for a complete 
duplex scan, the dictation must include arterial inflow, venous outflow, and color and spectral doppler.  
 
In reference to 93925, our reviewer found that the procedure report does not include sufficient documentation 
to confirm complete bilateral study. To assign the duplex codes, both spectral analysis and color flow must be 
documented. Duplex scans are a combination of ultrasound imaging, plus velocity measurements of blood flow 
(spectral analysis), and color flow.  This procedure cannot be verified in documentation submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound services coded as 93880 and 93925 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 93880, defined as a duplex scan of extracranial arteries; 
complete bilateral study, and code 93925, defined as duplex scan of lower extremity arteries or arterial bypass 
grafts; complete bilateral study, performed on February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right cervical level 4-5 foraminotomy (69990, 20660, 
63020). 
 
You asked the Plan to pre-approve right cervical level 4-5 foraminotomy. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria 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 right cervical level 4-5 foraminotomy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no recent trial of physical therapy. There is no correlation 
between the exam and magnetic resonance imaging (MRI) showing compression of nerve root and deficit.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right cervical level 4-5 foraminotomy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve right cervical level 4-5 foraminotomy (69990, 20660, 63020).
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's health will quickly deteriorate without 
aggressive therapy and careful monitoring of their comorbidities. The Plan denied your request. The Plan says 
the IRF services requested 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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: Favorable

 
We decided that the Plan has to pay for procedure code 99232 billed for dates of service from July 20, 2022, to 
July 21, 2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says that the provided records do not support services 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 99232 is: Subsequent hospital care, per day, for the evaluation and management of a patient, which 
requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded 
problem focused examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at 
the bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99232. Our reviewer says that procedure 
code 99232 meets criteria for payment. Our reviewer found that the records for July 20, 2022, and July 21, 
2022, contain expanded physical examinations and medical decision making of moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99232 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99232 billed for dates of service from July 20, 2022, to July 21, 2022.  
 
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 you believe that you need more therapy services to 
help you improve your mobility. 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 you do 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at T11 (22512, 22510).  

You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, greater than 25% 
vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is 
magnetic resonance imaging (MRI) corroboration of other plausible causes of the lower back pain. Therefore, 
the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 at T11 (22512, 22510).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. Skilled therapies as an outpatient or at a skilled nursing facility may be approved upon 
request. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 IRF admission and services.