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

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
(E2377), harness (E2313), gel pads (K0108), push handles (K0108), and cup holder (K0108).  
 You asked the Plan to pre-approve the power wheelchair accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says an electronic connection, expandable controller, and 
harness are not medically necessary and the gel pads, push handles, and cup holder do not serve a medical 
purpose. 
 
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 power wheelchair accessories. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has adequate upper body strength to control power options through the 
standard switches, there is no medical reason for an upgrade. 
 
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 power wheelchair accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), 
harness (E2313), gel pads (K0108), push handles (K0108), and cup holder (K0108).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile diagnostic services provided on March 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that the denial is incorrect. The Plan denied your 
request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We looked at the file and the rules. The claim was billed with 11, an office setting place of service code. The 
records do not show that the services at issue were provided in an office. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for the mobile diagnostic services provided on March 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service 
April 14, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 83520 is: Immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is: Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. 
 
We find that CPT codes 83520 and 87798 are not supported. Specifically, both codes are "not otherwise 
specified" codes. The case record does not identify the testing indicated by these codes. Codes 83520 and 
87798 cannot be verified in this case. Based on this information, we decided that Medicare rules for coverage 
of procedure codes 83520 and 87798 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 83520 and 87798 billed for date of service April 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for multiple pharmacogenetic genotype- phenotype panel assay 
(81225) provided February 27, 2023.  
 
You asked the Plan to pay for the laboratory service. You say that the service was provided at the treating 
physician's request and is medically necessary to better assist in medication management.  The Plan denied 
your request. The Plan says this item or service does not meet the criteria for the category under which it was 
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. 
 
In this case, the CPT Code Manual definition of code 81225 is CYP2C19 (cytochrome P450, family 2, 
subfamily C, polypeptide 19) (eg, drug metabolism) gene analysis, common variants (eg, *2, *3, *4, *8, *17).  
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 genetic testing. Our reviewer says that the documentation 
does not meet the criteria. Our reviewer found the laboratory does not include documentation to support CPT 
81225 has been performed.  For CPT 81225, The laboratory analyst performs the technical lab test to detect the 
presence of common changes in the gene for cytochrome P450, family 2, subfamily C, polypeptide 19, also 
known as CYP2C19. In this case, this procedure is not documented and therefore cannot be verified. In this 
case, unlisted molecular pathology procedure code, CPT 81479, should be billed for the service 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for multiple pharmacogenetic genotype- phenotype panel assay (81225) provided 
February 27, 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 April 28, 2023. 
 
You asked the Plan to pay for code 99223. You say that code 99223 is clearly supported by the medical record 
and these services were warranted. The Plan denied your request. The Plan says code 99223 is not supported by 
the medical record. The medical records do not support a high level of decision making or total time required 
of the code 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. 
 
In this case, the CPT Code Manual definition of code 99233 is Initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 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 record. Our reviewer found neither the level of medical decision making nor the time 
spent meet the requirements of this code. 
 
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 April 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 would like to return to being 
independent. The Plan denied your request. The Plan says the required services can be provided in an alternate 
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 
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 this 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 61651 billed for date of service November 23, 2022. 
 
You asked the Plan to pay for code 61651. You say that this code was billed corrected and is supported by the 
procedure note. The Plan denied your request. The Plan says code 61651 is not supported by the medical 
record. The Plan has agreed to pay for code 61650, so that code is not in dispute. 
 
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 61651 is endovascular intracranial prolonged 
administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, 
diagnostic angiography, and imaging guidance; each additional vascular territory (list separately in addition to 
code for primary procedure). 
 
 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 61651. Our reviewer says that code 61651 is not 
supported by the medical record. Our reviewer found per CPT guidelines, "Codes 61650, 61651 describe the 
cerebral endovascular continuous or intermittent therapeutic prolonged administration of any non-thrombolytic 
agent(s) (eg, spasmolytics or chemotherapy) into an artery to treat non-iatrogenic central nervous system 
disease or sequelae thereof.  These codes should not be used to report administration of agent (e.g., heparin, 
nitroglycerin, saline) usually administered during endovascular interventions.  These codes are used for 
prolonged administrations, ie, of at least 10 minutes continuous or intermittent duration". In this case, 
procedure report does not include time, 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 61651 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 61651 billed for date of service November 23, 2022.
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 you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (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 enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 practitioner services provided on March 13, 2023, billed with 
evaluation and management (EM) code 99205. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care is 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 99205 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 
We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical records provided does not 
include sufficient documentation to validate the CPT 99205 was performed on March 13, 2023, therefore, this 
procedure cannot be verified. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 13, 2023, billed with evaluation and 
management (EM) code 99205.
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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the service requested is not supported based on 
the records received.  
 
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 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.  
 
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 pre-approve a Nephrology office visit and follow up visit at a tertiary 
care center. 
 
You asked the Plan to pre-approve a Nephrology office visit and follow up visit at a tertiary care center. You 
say that the service is medically necessary. The Plan denied your request. The Plan says that the tertiary level 
of care is not medically necessary. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan PCPs are usually linked to certain hospitals and specialists. When you choose a 
PCP, it also determines what hospitals and specialists the PCP refers. 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 Nephrology office visit and follow up visit at a tertiary care center. Our 
reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found there is no 
medical reason why you are unable to receive these services at a community 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 a Nephrology office visit and follow up visit at a tertiary care center have not 
been met.  
 
The provider is a tertiary provider, and the services are available in-network at the community level. We found 
no exception that would require the Plan to pre-approve a Nephrology office visit and follow up visit at a 
tertiary care center. Therefore, we decided that the Plan does not have to pre-approve a Nephrology office visit 
and follow up visit at a tertiary care center.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve medial branch blocks. You say that medial branch blocks should be 
approved. The Plan denied your request. The Plan says there is no documented failure to respond to non-
invasive conservative care management or absence of untreated radiculopathy. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions are only covered if certain 
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 medial branch blocks. Our reviewer 
says that the enrollee does not meet criteria for these injections. Our physician reviewer found the enrollee has 
other significant pathologies which could be the source of pain and need to be explained. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) and core buildup 
(D2950) provided on June 14, 2023. 
 
You asked the Plan to pay for a porcelain/ceramic crown (D2740) and core buildup (D2950). You say that you 
had a crown. You also say it came out while you were eating. The Plan denied your request. The Plan says a 
porcelain/ceramic crown (D2740) and core buildup (D2950) are not a covered benefit under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
porcelain/ceramic crown (D2740) and core buildup (D2950) provided on June 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of Barostim Neo device. 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that the enrollee's condition is 
progressively worsening such that they qualify for this device to improve symptoms, functional capacity and 
quality of life since they remain symptomatic despite being on maximal tolerated dose of medical therapy. The 
Plan denied your request. The Plan says the Barostim Neo device is considered unproven and is 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 the Barostim Neo device. Our reviewer 
says that the requested Barostim Neo device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. Therefore, the 
reviewer found that the requested Barostim Neo device is 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 Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the implantation of Barostim Neo device.