Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a fall risk. They require IRF services 
in order to get stronger and address functional deficits. The Plan denied your request. The Plan says the request 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 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 you are struggling and declining at home, and you 
are unable to care for yourself. The Plan denied your request. The Plan says the 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 your nursing, medical, and rehabilitation needs does 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on December 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a diagnostic laboratory test using NGS must have 
Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. The Tempus xF test is not FDA approved. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for lab services (81455) provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 20, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you believed this provider was in-network. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on December 20, 2022, by 
an out-of-network (OON) provider.
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.  

You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. 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 power wheelchairs are 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 a group 3 power wheelchair with 
multiple power options. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found although the enrollee's condition may meet criteria for a power wheelchair, the criteria for this 
specifically requested power wheelchair with multiple power options including power tilt and recline 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 a group 3 power wheelchair with multiple power options 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99204 billed for date of service November 8, 2022. 
 
You asked the Plan to pay for code 99204. You say that the patient had at least two chronic medical conditions, 
so this visit was coded correctly. The Plan denied your request. The Plan says code 99204 is not supported by 
the medical record. The records do not support a moderate level of medical decision making or the total time 
required of the 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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: a comprehensive history; a 
comprehensive 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 patients and/or familys needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. 
 
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 code 99204. Our reviewer says that code 99204 is not 
supported by the medical record. Our reviewer found a comprehensive history requires a chief complaint, an 
extended history of present illness, a review of all additional body systems and a complete past, family and 
social history. A comprehensive examination requires a general multisystem examination or a complete 
examination of a single organ system and medical decision making of moderate complexity requires 2 out of 3 
of multiple diagnoses or management options, a moderate amount and complexity of data reviewed and 
moderate risk of complication. The provided records in this case document a chief complaint, an extended 
history of present illness, a review of all additional body systems and a complete past, family and social 
history. The provided records in this case do not document 2 out of 3 of multiple diagnoses or management 
options, a moderate amount and complexity of data reviewed and moderate risk of complication or that 45 
minutes were spent face-to-face with the patient and/or family. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99204 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99204 billed for date of service November 8, 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 this is medically necessary. The Plan denied your 
request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee could be 
treated 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 0017U) rendered on 
September 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service is not covered by Medicare. 
 
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that there was no specific clinical rationale for the obtained laboratory studies. 
 
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 pay for laboratory services (procedure code 0017U) rendered on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on November 21, 
2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Specifically, the rules say that there is sufficient evidence to 
conclude that the use of infrared therapy devices and any related accessories is not reasonable and necessary. 
Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided on 
November 21, 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 you feel that it would be safer for the enrollee to go 
through the rehabilitation process at the hospital than to be transferred to an outpatient facility. The Plan denied 
your request. The Plan says the enrollee's needs can be met 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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 pay for the revision of total knee arthroplasty and related services 
provided on August 30, 2022. 
 
You asked the Plan to pay for the revision of total knee arthroplasty and related services. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 27486 is not supported in the medical record. Specifically, this code is a status indicator 
"C" inpatient procedure. This code was billed in an outpatient setting. Since this was billed incorrectly, the 
remaining lines for this same date of service as an inpatient procedure are denied. Based on this information, 
we decided that Medicare rules for coverage of the revision of total knee arthroplasty and related services have 
not been met. Therefore, we decided that the Plan does not have to pay for the revision of total knee 
arthroplasty and related services provided on August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with advanced knee features (codes 
L5822, L5845, L5850, L5981, L5986). 
 
You asked the Plan to pre-approve the services. You say that with the enrollee's increased ambulation distance 
and endurance, they are in need of a well-fitting and functioning prosthesis. The Plan denied your request. The 
Plan says the requested prosthesis/prosthetic parts exceed the enrollee's need and cannot be approved. 
 
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 the enrollee uses an assistive device (walker) which is not consistent with a K3 level of ambulation. 
Furthermore, the enrollee's functional activities do not require the requested items, as they can be met with a 
simpler prosthetic leg, rather than the requested advanced knee and foot. 
 
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 a prosthetic leg with advanced knee features (codes L5822, L5845, L5850, L5981, L5986).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87502 for date of service December 22, 
2022. 
 
You asked the Plan to pay for procedure code 87502. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 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. 
 
We find that CPT code 87502 is not supported in the medical record. Specifically, the documentation does not 
support that 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 was completed. Based on this information, we decided that Medicare rules for 
coverage of procedure code 87502 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 87502 for date of service December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99212) provided from 
October 21, 2022, to October 22, 2022. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that you have correctly billed the 
services at issue. The Plan denied your request. The Plan says the reported outpatient visits were billed with an 
inpatient POS 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 99212 is: Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and straightforward medical decision making. When using time for code selection, 10-19 minutes 
of total time is spent on the date of the encounter. 
 
We find that CPT code 99212 is not supported. Specifically, the case record documents that the outpatient 
services at issue have been reported with an inpatient POS code. Based on this information, we decided that 
Medicare rules for coverage of an office or other outpatient visit have not been met. Therefore, we decided that 
the Plan does not have to pay for an office or other outpatient visit (99212) provided from October 21, 2022, to 
October 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36247 and 75710 billed for October 24, 
2022. 
 
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 code 36247 is not supported and 75710 is inclusive to another 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 36247 is selective catheter placement, arterial system; 
initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular 
family. 
 
We find that CPT code 36247 is not supported in the medical record. Specifically, there is no documentation of 
a selective catheter placement into the arterial system; initial third order or more selective abdominal, pelvic, or 
lower extremity artery branch. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met.  
 
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, we have confirmed that code 75710 
is a column II code to column I code 37242. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 36247 and 75710 billed for 
October 24, 2022.