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 IRF care is necessary. The Plan denied your request. 
The Plan says IRF care is not reasonable and 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 your nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. The medical records do not support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility. You 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a humidifier, heated, used with positive airway pressure 
device (E0562). 
 
You asked the Plan to pre-approve the heated humidifier. You say that the enrollee's previous non-invasive 
ventilator (NIV) was taken by the previous durable medical equipment (DME) company. You say that the 
enrollee's health has declined since then. You also say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a heated (E0562) humidifier is covered and paid 
separately when ordered by the treating practitioner for use with a covered E0470 or E0471 RAD. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the heated humidifier have not been met. Therefore, we decided that the Plan does not have to pre-
approve a humidifier, heated, used with positive airway pressure device (E0562).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37229. We decided that the Plan does not have to pay for 75710.  
 
You asked the Plan to pay for procedure codes 37229 and 75710 rendered on June 19, 2023.. You say that this 
should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 37229.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 37229 is 
"Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
atherectomy, includes angioplasty within the same vessel, when performed." 
 
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 for CPT 37229. Our reviewer says that this codes for 
tibial artery atherectomy with or without angioplasty. There is satisfactory documentation of atherectomy and 
angioplasty of the right anterior tibial artery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
37229.  
 
We also decided that the Plan does not have to pay for 75710. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 75710 is "Angiography, 
extremity, unilateral, radiological supervision and interpretation." 
 
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 for CPT 75710. Our reviewer says that this codes for 
unilateral extremity angiography. This is bundled into CPT 37229 code, unless there is documentation that no 
prior images are available or that there was a change in condition. As the documentation suggests that there 
was prior angiography, any extremity angiography is bundled in the procedure code and is not separately 
billable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 75710 have not been met. Therefore, we decided that the Plan does not have to 
pay for 75710. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the requested imaging is not 
medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when 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 MRI of the lumbar spine. Our reviewer 
says that the requested imaging is not medically necessary. Our physician reviewer found that the record 
provided does not document the presence of any red flag signs or symptoms or abnormal neurological findings. 
The record includes a normal nerve condition study and plain films from two years ago. The record does not 
document the trial and failure of a course of physical therapy. The requested service is not medically necessary 
and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of 
the coverage criteria are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI of the lumbar spine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) additional ostomy pouches per month (A5063, 
A4409). 
 
You asked the Plan to pre-approve additional ostomy pouches. You say that the additional ostomy bags are 
necessary for the enrollee due to bag leaks. The Plan denied your request. The Plan says the additional pouches 
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 additional ostomy pouches. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee's benefits include 20 bags per month, and he has had an 
additional 10 bags per month approved. The documentation stated the enrollee needs to change his ostomy bag 
daily and he now has approval for 30 bags/month. There is no documentation stating the necessity of additional 
bags beyond the 30/month. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional ostomy pouches have not been met. Therefore, we decided that the 
Plan does not have to pre-approve five (5) additional ostomy pouches per month (A5063, A4409).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seat lift mechanism that is electrically operated (E0627) 
and miscellaneous durable medical equipment, lift chair (E1399). 
 
You asked the Plan to pre-approve a lift chair. You say that you are appealing the denial of lift chair and lift 
mechanism. The Plan denied your request. The Plan says there is no documented clinical finding that would 
necessitate a chair lift/mechanism, therefore the medical necessity criteria for E0627 and E1399 are not met.  
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 lift chair. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not require a power seat lift chair per guideline criteria. The enrollee is noted 
to have chronic neck and low back pain as well as knee osteoarthritis that required a knee arthroplasty. The 
enrollee is noted to be able to ambulate with the assistance of a cane and is noted to have osteoarthritis of the 
knee joint but does not have a severe neuromuscular condition and there is no indication that the enrollee 
cannot independently transfer for a regular armchair or any chair in the home. Therefore, the requested power 
seat lift chair and lift mechanism (E0267 & E1399) are not medically 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 a lift chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve seat lift mechanism that is electrically operated (E0627) and miscellaneous durable medical 
equipment, lift chair (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Depo-Testosterone (testosterone cypionate). 
 
You asked the Plan to pre-approve Depo-Testosterone (testosterone cypionate). You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Depo-Testosterone (testosterone 
cypionate). Our reviewer says that the documentation does not support that the requested drug is medically 
reasonable or necessary. Our physician reviewer found the enrollee has had two readings of testosterone levels. 
In this case, the record is insufficient to establish the diagnosis and medical necessity of the requested service. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Depo-Testosterone (testosterone cypionate) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Depo-Testosterone (testosterone cypionate).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on February 28, 2023, billed with 
codes 87486, 87541, 87581, 87631, 87798, U0004, and U0005. 
 
You asked the Plan to pay for the panel testing billed. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87486, 87541, 87581, 87631, 87798, U0004, and U0005 are not supported in the 
medical record. Specifically, a panel was performed and there is a more appropriate singular code for the 
services. 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 pay for the panel testing provided on February 
28, 2023, billed with codes 87486, 87541, 87581, 87631, 87798, U0004, and U0005.
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 requested IRF services are medically necessary. 
The Plan denied your request. The Plan says the enrollee's condition does not meet Medicare guidelines for 
services in 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 the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute rehabilitation 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 does not support that they would meet criteria for admission to an IRF.  There is no indication 
that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours 
a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain their 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided October 31, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 3 key components: 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 problem(s) requiring 
admission are of high severity. Typically, 70 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 service. Our reviewer found although the notes have a 
comprehensive history and exam, the medical decision making is not high complexity and there is no 
documentation of time. Therefore, the notes do not support this level of billing. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (99223) provided October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cerapedics I-Factor allograft for spinal fusion surgery. 
 
You asked the Plan to pre-approve Cerapedics I-Factor allograft. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the clinical value and effectiveness of 
Cerapedics I-Factor allograft in the setting of spinal fusion surgery have not been demonstrated. 
 
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 Cerapedics I-Factor allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited large-scale, long-term peer-reviewed literature that shows this requested allograft to be safe and effective treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cerapedics I-Factor allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cerapedics I-Factor allograft for spinal fusion surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection testing provided on February 28, 
2023. 
 
You asked the Plan to pay for 87529. You say that the records support the medical necessity of this service. 
The Plan denied your request. The Plan says the documentation does not support this code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87529 is infectious agent detection by nucleic acid; 
herpes simplex virus, amplified probe technique.  

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 87529. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the documentation and lab orders submitted do not support the billing 
of code 87529. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87529 have not been met. Therefore, we decided that the Plan does not have to 
pay for infectious agent detection testing provided on February 28, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 26 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you are functioning without pain at the community level. You are able 
to continue with a home exercise program. You do not require continued unique input from a skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 26 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87498, 87502, 87634, 87798 
provided February 21, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that please review the medical notes and 
reprocess for payment. The Plan denied your request. The Plan says this request is not medically necessary 
because your records show that this extended panel was not performed by a clinical specialist. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation, this extensive of testing was not medically reasonable or 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 87498, 87502, 87634, 87798 provided February 21, 
2023.