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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF services 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95927, 95907, 95885) provided on October 11, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. 
 
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 the services. Our reviewer says that the use of codes 95927, 
95907, and 95885, is not supported by the records provided. Our reviewer found that the medical records 
provided do not include sufficient documentation to validate code 95927 as a distinct separate service. It is 
documented that the ulnar nerve was stimulated with recording at Erb's point, and in this case is inclusive to the somatosensory evoked potential (SSEP) of the ulnar nerve. Therefore, code 95927-26-XS is not eligible for 
reimbursement consideration. For code 95907, the records indicate pedicle screw stimulation, which are not 
baseline nerve conduction studies, therefore this code cannot be verified. For code 95885, the records provided 
do not include sufficient documentation to validate that a needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
limited (List separately in addition to code for primary procedure), as pedicle screw stimulations are not 
baseline nerve conduction studies. 
 
We looked at this coder'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 the services (95927, 95907, 95885) provided on October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L3-L5 minimally invasive lumbar 
decompression (MILD) procedure. 
 
You asked the Plan to pre-approve MILD procedure. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MILD procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MILD procedure is experimental for back pain. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MILD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bilateral L3-L5 minimally invasive lumbar decompression (MILD) procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on September 7, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange.  
 
We looked at the file and Medicare rules. The requested test is not covered under DEX Diagnostics Exchange. 
Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the testing provided on September 7, 2022.
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 you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the request for admission to an 
IRF is not medically necessary at this time. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service November 
16, 2022. 
 
You asked the Plan to pay for procedure code 88321. You say that this is not a duplicate claim. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Although these services were billed by two providers, these providers have the same 
primary specialty/taxonomy code and are part of the same physician group. Based on this information, we 
decided that Medicare rules for coverage of procedure code 88321 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 88321 billed for date of service November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rehabilitation seat frame, height adjustable flip back 
armrests, and privacy flap for seat. 
 
You asked the Plan to pre-approve a rehabilitation seat frame, height adjustable flip back armrests, and privacy 
flap for seat. You say that the items are necessary. The Plan denied your request. The Plan says the requested 
items are convenience items that are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a rehabilitation seat frame, height adjustable flip back 
armrests, and privacy flap for seat.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on July 22, 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 Current Procedural Terminology (CPT) code 99285 (1 unit) remains 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical decision making was 
not of high complexity. The enrollees condition did not pose an immediate threat to life or function. As such, 
the billing of CPT 99285 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (procedure code 99285) rendered on July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft, morselized, or placement of osteopromotive 
material, for spine surgery only (20930). 
 
You asked the Plan to pre-approve an outpatient procedure. You say that the device is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the request does not meet the Medicare or health plan 
coverage criteria. Evidence is lacking, the device is unproven and 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 an outpatient procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found osteopromotive allograft is experimental and investigational in spine surgery. Iliac 
crest autograft is the gold standard. There is more research needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve allograft, morselized, or placement of osteopromotive material, for spine surgery 
only (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered on 
June 23, 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 the documents do not support this level of care. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documented history on June 
23, 2022 was brief and focused, and described the enrollee as status post kyphoplasty. It described the enrollee 
with improved pain off Norco for three days. The physical examination was brief, focused, and unremarkable. 
The enrollee was treated with ongoing fluids, analgesics, and home meds with plans to continue to monitor 
only and was otherwise stable. The records do not sufficiently support a comprehensive history or physical, nor 
was there support for medical decision-making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered on June 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wireless capsule endoscopy. 
 
You asked the Plan to pre-approve wireless capsule endoscopy. You say that the site of bleeding could not be 
identified with upper endoscopy and colonoscopy followed. The Plan denied your request. The Plan says the 
records do not show that the enrollee has had a colonoscopy within the past 12 months and therefore do not 
show that a colonoscopy has failed to reveal a source of bleeding. 
 
The Plan follows Medicare rules. Medicare rules state that wireless capsule endoscopy may be covered for 
investigation of GI bleeding for enrollees who have had upper and lower GI endoscopies 
(esophagogastroduodenoscopy and colonoscopy) within the past 12 months that have failed to identify a 
bleeding source. 
 
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 wireless capsule endoscopy. Our 
reviewer says that the enrollee does not meet criteria for this wireless capsule endoscopy. Our physician 
reviewer found no colonoscopy report was provided for review. In addition, esophagogastroduodenoscopy (EGD) showed erosive gastritis which is a likely source of the enrollee's presenting melena. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve wireless capsule endoscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you need the device for the treatment of 
severe COPD and chronic respiratory failure. The Plan denied your request. The Plan says the request for a 
home mechanical ventilator set in PSV mode without Auto-EPAP (AE) that could be delivered by BiPAP is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you were recently hospitalized and 
have a diagnosis of COPD. An arterial blood gas done a few months ago was consistent with mild acute on 
chronic hypercarbic respiratory failure. There are no pulmonary function tests to confirm airways obstruction 
or assess severity. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. There is no 
ABG done while stable to confirm chronic CO2 retention. If that is present, you may benefit from BiPAP with 
AVAPS during sleep. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from an 
LTACH admission for oxygen weaning, physical therapy, and occupational therapy. The Plan denied your 
request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 you are requesting an expedited reconsideration 
stating the enrollee meets Medicare criteria for an IRF admission that cannot be accomplished at a lower level 
of care. 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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires 3-4 weeks of 
LTACH services. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.