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 the services are medically necessary for the 
enrollee's needs. The Plan denied your request. The Plan says the enrollee's records do not show that they need 
an intensive team for their 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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service December 6, 2022, 
and December 8, 2022. 
 
You asked the Plan to pay for procedure code 99233. 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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high 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 unstable or has developed a significant complication or a significant new problem. Typically, 35 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 99233. Our reviewer says that the 
documentation does not support the services billed. Our reviewer found the provided records do not document 
a chief complaint, an extended history of present illness, a problem pertinent review of systems and a pertinent 
past, family and social history or an extended examination of the affected body area for the dates of service. 
The documentation submitted does not support a detailed interval history and a detailed examination. 
Therefore, code 99233 is not supported. 
 
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 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 for date of service December 6, 2022, and December 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on October 1, 2022. 
 
You asked the Plan to pay for critical care. You say that these services were medically necessary and were 
reported appropriately. The Plan denied your request. The Plan says the code used to report the services 
provided is not supported in the medical record. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records indicate that only 
20 minutes were spent providing these services on the date in question. The reported code requires a minimum 
of 30 minutes. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) provided 
on October 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services billed for date of service August 25, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes remain 
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, we have confirmed that codes 87150, 87481, 87653, 87798, and 87641 are column II codes to 
column I code 87801. The codes at issue have not been billed with an appropriate modifier to bypass the edit.  
 
The CPT Code Manual definition of code 87801 is infectious agent detection by nucleic acid (DNA or RNA), 
multiple organisms; amplified probe(s) technique. We find that 3 units of 87801 is not supported in the medical 
record. The records and claim do not specify the organisms represented by this code.  
 
We find that codes 87150, 87798, 87801, 87641, and 87500 were billed with the -XU modifier. The records do 
not indicate the testing services were unusual non-overlapping services. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services billed for date of service August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivery of meals. 
 
You asked the Plan to pre-approve home delivery of meals. You say that you are appealing the denial for home 
delivered meals because you cant stand long enough to cook. The Plan denied your request. The Plan says you 
did not have a principal diagnosis of congestive heart failure and you were also discharged to a skilled nursing 
facility. 
   
Medicare generally does not cover home delivery of meals. However, the Plan offers a supplemental benefit 
that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan will 
cover meals delivered to your home immediately following discharge from a network hospital as an inpatient 
due to congestive heart failure.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plans rules for 
coverage of home delivery of meals have not been met. Therefore, we decided that the Plan does not have to 
pre-approve home delivery of meals.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) care provided from March 1, 2021, to 
March 31, 2021, at the original rate billed. 
 
You asked the Plan to pay for SNF care at the original rate billed. You say that these services were medically 
necessary and were reported appropriately. The Plan denied your request. The Plan says that these services 
were previously overpaid. 
 
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 has provided no clear explanation as to why the original 
rate code billed is not appropriate, and the Plan has not supported this change with documentation and a 
relevant citation. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care provided 
from March 1, 2021, to March 31, 2021, at the original rate billed.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service August 18, 
2022.  
 
You asked the Plan to pay for procedure code 88377. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88377 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88377 billed for date of service August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the enrollee is over the covered age range for this test. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is not 55 to 77 years of age. Therefore, 
we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Proteor Shockwave foot (L5984, L5987) and the 
Blatchford Orion knee (L5828, L5845, L5848, L5856). 
 
You asked the Plan to pre-approve the requested foot and knee for a prosthesis. You say that it is felt that the 
requested items are necessary. The Plan denied your request. The Plan says the enrollee is at level 1 function 
and uses a wheelchair. There is not sufficient evidence to support the likelihood of reaching level 3.  
 The Plan follows Medicare rules. Medicare rules say that the requested types of knee and foot for the prosthesis 
are covered for enrollees at functional level of 3 or higher. 
 
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 requested foot and knee for a 
prosthesis. Our reviewer says that the requested knee and foot systems are not shown to be reasonable and 
necessary.  Our physician reviewer found the enrollee is a 59-year-old male with a past medical history 
including diabetes mellitus, peripheral vascular disease, and cardiac disease with a previous left-sided above 
the knee amputation who is requesting a replacement prosthesis. The documentation indicates the enrollee is a 
K1 level functional ambulator. He uses a wheelchair for locomotion. The documentation does not support the 
medical necessity for K3 level components for a replacement prosthesis including a Proteor Shockwave foot 
and a Blatchford Orion knee. In this case, the documentation does not support that the enrollee is able to 
ambulate at a functional level of 3.   
 
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 requested foot and knee for a prosthesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Proteor Shockwave foot (L5984, L5987) and the 
Blatchford Orion knee (L5828, L5845, L5848, L5856).
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 it is medically necessary. The Plan denied your 
request. The Plan says it 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 rehabilitation therapy services can be delivered in a wide variety of settings 
across the care continuum. Post-acute settings differ in the types of available rehabilitation therapies, intensity 
of therapy, and the level of medical and nursing support. Acute inpatient rehabilitation facilities are settings 
were complex medical needs and functional needs combine. The requirements for admission to an inpatient 
rehabilitation facility (IRF) include a need for 24-hour rehabilitation nursing care, a minimum of three 
physician face-to-face visits per week and a minimum of three hours of therapy daily at least five days per 
week (or at least 15 hours over a seven-consecutive day period). Additionally, an individual requires multiple 
types of therapies one of which should be physical or occupational therapy. In this case, the complexity of the 
enrollees nursing, medical and rehabilitation needs do not require an acute rehab 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 doesnt support that the enrollee 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, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain his 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the heart with 
quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve a CT scan of the heart with quantitative evaluation of coronary calcium. 
You say that this is medically necessary. The Plan denied your request. The Plan says there is no covered 
indication for this request. 
 
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 CT scan of the heart with quantitative 
evaluation of coronary calcium. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is insufficient support in 
the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with quantitative 
evaluation of coronary calcium in guiding optimal management. As such, this service is considered 
experimental/investigational for the evaluation and management of your medical condition. 
 
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 CT scan of the heart with quantitative evaluation of coronary calcium have 
not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) 
scan of the heart with quantitative evaluation of coronary calcium.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nulojix. 
 
You asked the Plan to pre-approve Nulojix. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says Nulojix is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
  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 Nulojix. Our reviewer says that Nulojix 
is not medically necessary. Our physician reviewer found that Nulojix is Food and Drug Administration (FDA) 
approved for prophylaxis of renal transplant rejection in patients who are Epstein Barr virus (EBV) seropositive 
in combination with basiliximab induction, mycophenolate mofetil, and corticosteroids. Provided records in 
this case report the enrollee is EBV negative or serostatus is unknown and the Nulojox will not be used in 
combination with basiliximab induction. The use of Nulojix is not supported by one of the major drug 
compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nulojix. have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nulojix.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the CardioMEMS pulmonary artery 
pressure monitor.  
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that there is enough evidence to show 
that this procedure is beneficial, and it should be covered.  The Plan denied your request. The Plan says the 
evidence is not sufficient to support the need for this procedure.  
 
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 CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a lack of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's 
clinical management. 
 
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 CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the CardioMEMS pulmonary artery pressure monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial foot shoe insert toe filler (L5000). 
 
You asked the Plan to pre-approve partial foot shoe insert toe filler. You say that you are a fall risk without 
this. The Plan denied your request. The Plan says there is not a standard written order or prescription for this 
prosthesis. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order is required for coverage 
of lower limb prosthetic components.  
 
We looked at the file and Medicare rules. A standard written order was not submitted regarding this partial foot 
shoe insert toe filler. This should be submitted to support coverage. Based on this information, we decided that 
Medicare rules for coverage of partial foot shoe insert toe filler have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a partial foot shoe insert toe filler (L5000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep apnea device (Inspire) 
 
You asked the Plan to pre-approve the Inspire device. You say that you cannot use the standard sleep apnea 
machine and need the implanted machine because you are not doing well. The Plan denied your request. The 
Plan says a timely decision was not made by the Plan. 
 
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 Inspire device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have coronary artery disease and a body mass index of 31.9. Documentation of a 
clinical visit on December 28, 2022, makes no mention of sleep symptoms or obstructive sleep apnea. Our 
reviewer found that a polysomnography on February 23, 2023, showed obstructive sleep apnea with an apnea-
hypopnea index of 30.8. Auto titrating continuous positive airway pressure (CPAP) was recommended. Our 
physician reviewer also found that there is no documentation that CPAP has been tried or that you are 
intolerant of CPAP. 
 
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 Inspire device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sleep apnea device (Inspire)