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

 
We decided that the Plan has to pre-approve therapeutic facet joint injections (64493 and 64494). 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says that these injections are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that 
the requested services are medically reasonable and necessary. Our physician reviewer found that this is a 
therapeutic facet block, not diagnostic, in an enrollee who refused radiofrequency ablation. The enrollee had 
medial branch blocks at L4-L5 and L5-S1 and achieved 100% pain relief for 6 months. The request is to repeat 
this block; therefore, the request is deemed medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have been met. Therefore, we decided that the Plan has to pre-
approve therapeutic facet joint injections (64493 and 64494).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 provided on January 23, 2023. 
 
You asked the Plan to pay for procedure code 99232. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes E11.621 and E08.621 should not be reported together. Therefore, we decided that the Plan 
does not have to pay for procedure code 99232 provided on January 23, 2023.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 
level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 You asked the Plan to pre-approve home health services. You say that you have provided medical records to 
support this request. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
had a stable episode of care and no longer requires skilled nursing observation or education and is not receiving 
other skilled nursing intervention. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99100 and 00142) provided on 
January 16, 2023. 
 You asked the Plan to pay for procedure codes 99100 and 00142. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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 procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Procedure code 00142 does not have a global period of 0, 10, 
or 90 days and therefore should not have been billed with Modifier -22. Based on this information, we 
decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services (99100 and 00142) provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service August 29, 2022. 
 
You asked the Plan to pay for code 99223. You say that this claim was coded correctly. The Plan denied your 
request. The Plan says code 99223 billed for date of service August 29, 2022, is not supported in the medical 
record. The record doesn't support a comprehensive history. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history, 
a comprehensive exam, and medical decision making of high complexity. 
 
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 99223. Our reviewer says that code 99223 is not supported by the medical records. Our reviewer found the procedure report describes and expanded problem 
focused history; comprehensive exam; and medical decision making of high complexity.  There is a more 
appropriate code to report for the service provided, as a comprehensive history was not documented in the 
report, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service August 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 2, 2022 to 
August 12, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly. The Plan denied your request. The Plan says secondary diagnosis code G93.41 is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93.41. 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that the medical record includes insufficient documentation to confirm metabolic 
encephalopathy. There is no consistent documentation of encephalopathy with a plan of care throughout the 
hospital stay. The documentation supports confusion and agitation related to alcohol withdrawal.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 2, 2022 to August 12, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
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 the enrollee had elective back surgery are requires 
rehabilitation. The Plan denied your request. The Plan says that 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 that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Medmizer Ex8000 bariatric total electric bed, a non-
powered advanced pressure reducing mattress (E0373), and trapeze bars (E0910). 
 
You asked the Plan to pre-approve a Medmizer Ex8000 bariatric total electric bed, a non-powered advanced 
pressure reducing mattress (E0373), and trapeze bars (E0910). You say that due to the enrollee's condition they 
are at risk of developing pressure ulcers. You say that the nonpowered pressure mattress will aid in prevention 
and treatment of pulmonary and skin complications associated with immobility. You also say that the requested 
bed and accessories are the simplest that will meet the enrollee's needs. The Plan denied your request. The Plan 
says that total electric hospital beds are not a covered benefit. The Plan says there is no evidence of multiple 
pressure ulcers. The Plan also says as the bed and mattress do not meet coverage criteria the trapeze bars 
cannot be considered reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that total electric beds are non-covered. The rules also say 
that trapeze equipment is covered if the beneficiary needs this device to sit up because of a respiratory 
condition, to change body position for other medical reasons, or to get in or out of bed. Finally, the rules state 
that group 2 pressure reducing support surfaces are only covered if the beneficiary has pressure ulcers located 
on the trunk or pelvis or a myocutaneous flap. 
 
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 Medmizer Ex8000 bariatric total 
electric bed, a non-powered advanced pressure reducing mattress (E0373), and trapeze bars (E0910). Our 
reviewer says that the requested items are not medically necessary. Our physician reviewer found the enrollee 
is obese but she does not have stage 2 pressure ulcers and no recent surgery of skin flap. She is dependent and 
max assist in mobility. She does not have skin conditions or recent surgery requiring a group 2 mattress and 
there is no evidence she is able to use the trapeze to sit up in bed or transfer. 
 
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 Medmizer Ex8000 bariatric total electric bed, a non-powered advanced pressure reducing mattress (E0373), and trapeze bars (E0910) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Medmizer Ex8000 bariatric total electric bed, a non-powered advanced 
pressure reducing mattress (E0373), and trapeze bars (E0910).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) comprehensive 
genomic profiling test provided on March 24, 2022.  
 
You asked the Plan to pay for the F1Heme testing. You say that this testing was medically necessary.  The Plan 
denied your request. The Plan says this test is not covered.  
 
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 F1Heme testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case consist of the test requisition and the test results with no 
clinical information indicating how these test results would be used for this specific enrollee nor that it was 
furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the 
enrollee's condition. Medicare rules for coverage are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the F1Heme testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the FoundationOne Heme (F1Heme) comprehensive genomic profiling test provided 
on March 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 19, 2022, at 
the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly The Plan denied your request. The Plan says secondary diagnosis codes G93.41 and 
J96.01 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis codes G93.41 and J96.01. 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that in terms of G93.41, metabolic encephalopathy is not supported by 
the documentation submitted. There is no supporting documentation including altered mental status, cause, and 
diagnostic testing. This code cannot be verified. In terms of J96.1, a diagnosis and plan of care for acute 
respiratory failure cannot be found in the records. Therefore, this diagnosis cannot be verified.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 19, 2022, at the Diagnosis Related Group (DRG) originally 
billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 14, 2022 to May 
16, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the documentation did not validate the 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.01. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the medical record does not include sufficient clinical documentation to support acute 
respiratory failure. The documentation does not include arterial blood gasses; as well as signs/symptoms 
relating to acute respiratory failure with hypoxia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 14, 2022 to May 16, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the prior injection did not provide enough relief. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the guidelines require 50% pain relief for three months. 50% pain relief was achieved, but the next 
injection was requested only a month later. Therefore, the request is deemed not medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit and to pay 
for the self-administered drugs (i.e., the silver nitrate stick) you received in the ER. 
 
You asked the Plan to waive the copayment for the ER visit and to pay for the drugs. You say that you tried to 
avoid going to the ER because you cannot afford it.  You used the ER because you had to. The Plan denied 
your request. The Plan says this cost sharing for the ER visit was charged correctly. The Plan also says that the 
self-administered drugs you received are not covered under your medical benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for ER visits. You have been asked to pay $110 copayment for the ER visit.  This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan, and it applies regardless of the reason 
for the ER visit. 
 
In addition, Medicare rules state that self-administered drugs are not covered under your medical benefits. The 
silver nitrate stick that you received is a self-administered drug.  
 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) visit 
or pay for the self-administered drugs (i.e., the silver nitrate stick) you received in the ER.  
 
Benefits for the silver nitrate stick may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.