Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the repair or non-routine service for durable 
medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 
minutes (K0739) provided January 10, 2023. 
 
You asked the Plan to reimburse you for the repair or non-routine service. You say that you have provided the 
required information as best as you can and feel it meets the criteria for positive consideration. The Plan denied 
your request. The Plan says the service was rendered by a provider who is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the repair or non-routine 
service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor 
component, per 15 minutes (K0739) provided January 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is the only chance the enrollee 
may have at returning to a prior level of activity and independence. The Plan denied your request. The Plan 
says the enrollee can receive therapy at a lower level of care such as a skilled nursing facility (SNF), as an 
outpatient, or with home health services.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot be safely discharged home. They 
require IRF services to regain your prior level of functioning. 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 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 the evaluation and management services described by code 
99212-25 billed for date of service February 26, 2021. 
 
You asked the Plan to pay for 99212-25. You say that 99212-25 should be paid as billed because it was a 
significant and separately identifiable evaluation and management service unrelated to the decision to perform 
the minor surgical procedure. The Plan denied your request. The Plan says 99212-25 is denied because it was 
billed on the same date as a minor procedure (97597) and documentation does not support a significant and 
separately identifiable evaluation and management service unrelated to the minor surgical procedure.  
 
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 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 99212-25. Our reviewer says that 99212-25 is not supported in the documentation. Our reviewer found the enrollee is a 79-yr old who received services on February 26, 
2021. The procedure report documents: "Type of Visit: clinic follow up/wound care." Documentation does not 
support significant, a separately identifiable evaluation and management service above and beyond that 
associated with the wound care provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99212-25 have not been met. Therefore, we decided that the Plan does not have 
to pay for the evaluation and management services described by code 99212-25 billed for date of service 
February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 18, 2023, to 
February 23, 2023, 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 accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of A41.89 (other specified 
sepsis) and G93.41 (metabolic encephalopathy). 
 
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 codes A41.89 defined as other specified 
sepsis and G93.41 defined as metabolic encephalopathy. 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 physician reviewer found there was no 
documented oliguria. Although creatinine was elevated, this is only a Sequential Organ Failure Assessment 
(SOFA) score of 1. The patient's mental status was back to baseline on admission and after fluid administration. 
Therefore, the Sepsis 3 criteria was not met as there was insufficient support for a dysregulated response to 
infection leading to organ failure. Also, the documentation does not support a metabolic encephalopathy. 
Therefore, codes A41.89 (other specified sepsis) and G93.41 (metabolic encephalopathy) are each not 
supported.  
 
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 February 18, 2023, to February 23, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has symptoms thought to 
be due to chronic systolic heart failure,despite medical management, in the setting of severely reduced left 
ventricular function. The Barostim Neo system was approved by the Food and Drug Administration (FDA) in 
2019 but there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be considered medically reasonable and necessary in the 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Barostim Neo system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 
14, 2023, to July 19, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were never 
informed of your benefits. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $250 
copayment for inpatient hospital care. 
 
You have been asked to pay a $250 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital care benefit category. 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. You have been asked to pay a total of $1,250 for the inpatient hospital stay ($250 
copayment x 5 days = $1,250). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 14, 
2023, to July 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 13, 
2023, to September 9, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that there aren't any contracted providers in the 
patient's area. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 13, 2023, to September 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT scan) of the abdomen and 
pelvis and low osmolar contrast material (iodine concentration) billed with codes 74177 and Q9967 provided 
on July 25, 2023. 
 
You asked the Plan to pay for the CT scan and iodine concentration. You say that the services were billed 
correctly and should be paid. The Plan denied your request. The Plan says if no bilateral code is provided and 
the condition is bilateral, providers must assign separate codes for both the left and right side. When a patient 
has a bilateral condition and each aside is treated during separate encounters, assign the bilateral code, 
including for the encounter to treat the first side. The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM code for an unspecified side 
condition should only be used rarely in certain situations where the afflicted side cannot be determined.  
 
We find that the primary diagnosis code reported on this claim, R10.30 (lower abdominal pain, unspecified), is 
not supported or appropriate in this case. Specifically, the records provided indicate that this issue is bilateral. 
This means that the bilateral ICD-10-CM code should be reported in this case. Based on this information, we 
decided that Medicare rules for coverage of the CT scan and iodine concentration have not been met. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT scan) of the 
abdomen and pelvis and low osmolar contrast material (iodine concentration) billed with codes 74177 and 
Q9967 provided on July 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has rehabilitation needs that require an 
IRF admission, and they can tolerate the required therapy. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 6, 2023, to July 28, 
2023. 
 
You asked the Plan to pay for the home health services. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says you billed with an incorrect Type of Bill code. 
 
The Plan must follow Medicare rules. The rules state that the Type of Bill code is a 4-digit alphanumeric code 
that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim).  
 Based on this rule, this claim should have been billed with either Type of Bill code 0329 or 0327.  Instead, you 
billed with Type of Bill code 0323, which is incorrect. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from July 6, 2023, to July 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's clinical condition meets the full acute 
inpatient rehabilitation criteria. 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 such as at a skilled nursing facility (SNF), 
on an intermittent basis at home with home health care, or in a long-term care setting.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 00520-QX billed for date of service March 28, 2023. 
 You asked the Plan to pay for code 00520-QX. You say that the nurse anesthetist performed services during 
chest surgery, and the medical documentation supports the services billed. The Plan denied your request. The 
Plan says the diagnosis code at issue is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code J91.0. This code is 
not an appropriate primary diagnosis as the code has a Code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for code 00520-QX billed for date of 
service March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1843). 
 
You asked the Plan to pre-approve a knee orthosis. 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 knee orthoses 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 knee orthosis. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no evidence of recent injury, 
surgery, or instability on a physical examination.  
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1843).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care provided in Mexico from July 17, 2023, 
through July 19, 2023 
 
You asked the Plan to pay for the hospital care. You say that the Plan covers this emergency care provided 
outside of the United States. As such, payment should not be denied. The Plan denied your request. The Plan 
says the Plan's worldwide emergency coverage requires that the enrollee pay out-of-pocket for the services 
rendered and request reimbursement. The claim submitted from the foreign provider is not payable directly. 
 The Plan must follow Medicare rules. Medicare rules say that most foreign medical care is not covered by 
Medicare. The Plan's contract does offer supplemental coverage; however, this requires that the services be 
paid up front, with reimbursement being requested by the enrollee. 
 
In this case, there is no evidence that the enrollee paid these services up front as the provider directly submitted 
the claim to the Plan. Therefore, we decided that the Plan does not have to pay for the hospital care provided in 
Mexico from July 17, 2023, through July 19, 2023