Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional skilled nursing visits (G0299 x7). 
 
You asked the Plan to pre-approve seven additional skilled nursing visits. You say that you still need 
assistance. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional skilled nursing visits. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
clinical documentation does not show any clinical status changes, changes in plan of care or medications. Thus, 
the records do not show that 7 additional skilled nursing visits would be required in the home setting to 
effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a 
maintenance program to maintain your condition and/or prevent deterioration. 
 
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 additional skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 7 additional skilled nursing visits (G0299 x7).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastric peroral endoscopic myotomy (G-POEM) 
procedure (43999, 43235). 
 
You asked the Plan to pre-approve a G-POEM 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 a G-POEM procedure. 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 medical records provided there is no documentation that the G-POEM at 
issue in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. The most recent gastric emptying study in this case was over two years ago and it was reported as normal at 4 hours. 
Records report the enrollee's gastroparesis is "diet controlled". In addition, a recent published study concludes: 
"G-POEM is an effective 4-year treatment in patients with RG [refractory gastroparesis], especially in DG 
[diabetic gastroparesis], establishing a potential first-line therapy in these patients. However, randomized 
controlled clinical trials are needed to confirm these results. (Clinical trial registration number: 
NTC03126513.)," indicating further study is needed with regard to this procedure in the treatment of 
gastroparesis. 
 
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 G-POEM procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a gastric peroral endoscopic myotomy (G-POEM) procedure (43999, 43235).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements. Services needed may 
be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve panniculectomy. You say that the enrollee is developing rashes due to the 
excess skin. The Plan denied your request. The Plan says the medical 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 panniculectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record provided does not document the presence of intertrigo refractory to conservative treatment or the presence of a stable weight for the past six months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy.
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 the device is to be used for the treatment of 
COPD. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of a 
ventilator. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the 
enrollee was treated with BiPAP and ordered average volume assured pressure support (AVAPS) mode upon 
discharge. The provided primary source documentation does not contain sufficient detailed information in the 
medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with 
AVAPS capability and failure of such a device has not been documented. The plan has indicated coverage for 
such a device is available upon request. The elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99222) provided on January 26, 2023. 
 
You asked the Plan to pay for initial hospital care (99222). You say that the description is in the attached 
records and the code should be reconsidered for reimbursement. The Plan denied your request. The Plan says 
the medical records submitted do not support a comprehensive history. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
  In this case, the CPT Code Manual definition of code 99222 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 moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 55 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 initial hospital care (99222). Our reviewer says that the level 
of service billed is not supported. Our reviewer found that a comprehensive history and moderate level of 
decision making is not supported in the medical record. There is a more appropriate code that should be 
reported 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 initial hospital care (99222) have not been met. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99222) provided on January 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on January 26, 2023, billed with 
procedure codes 95939-26, 95865-26, and 95868-26-XS. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 95939-26, 95865-26, and 95868-26-XS is central motor 
evoked potential study (transcranial motor stimulation); in upper and lower limbs, needle electromyography; 
larynx, and needle electromyography; cranial nerve supplied. 
 
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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the procedure report does not include 
sufficient documentation to confirm results of procedure, as interpretation of testing was not found in medical 
record. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on January 26, 2023, billed with procedure codes 
95939-26, 95865-26, and 95868-26-XS.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life2000 system (E0466). 
 
You asked the Plan to pre-approve the Life2000 system. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 the Life2000 system. Our reviewer says 
that the enrollee does not need this item. Our physician reviewer found the Life2000 system is not a true 
ventilator because it is not capable of providing full ventilatory support. It is intended to be used during 
activity, and there is inadequate evidence that it is beneficial in the treatment of any chronic lung disease.  
 
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 Life2000 system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Life2000 system (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complex trunk repair (13101 and 13102) provided on 
February 2, 2023. 
 
You asked the Plan to pay for the complex trunk repair (13101 and 13102). You say that the attached notes 
support the necessity of the procedure, and the claim should be reviewed. The Plan denied your request. The 
Plan says the medical records submitted do not support procedure codes 13101 and 13102. 
 
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 13101 is repair, complex, trunk; 2.6 cm to 7.5 cm. The 
CPT Code Manual definition of code 13102 is repair, complex, trunk; each additional 5 cm or less (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 the complex trunk repair (13101 and 13102). Our reviewer 
says that the services do not meet the criteria for coverage. Our reviewer found that a complex repair must 
include exposure of bone, cartilage, tendon, or named neurovascular structure. In this case, the documentation 
does meet the criteria for a complex closure and there is a more appropriate code to report for the services 
documented. 
 
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 complex trunk repair (13101 and 13102) have not been met. Therefore, we 
decided that the Plan does not have to pay for the complex trunk repair (13101 and 13102) provided on 
February 2, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive urine drug testing (UDT) for 22 or more drug classes 
(G0483) provided on January 19, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing should 
be covered. The Plan denied your request. The Plan says that only 12 drug classes were tested. 
 
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 G0483 is the definitive urine drug testing of 22 or more drug classes.  
 
We find that CPT code G0483 is supported in the medical record. Specifically, the record shows that 22 or 
more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the 
definitive UDT for 22 or more drug classes have been met. Therefore, we decided that the Plan has to pay for 
the definitive urine drug testing (UDT) for 22 or more drug classes (G0483) provided on January 19, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound PCR (polymerase chain reaction) panel (87798, 
87801, 87640, 87641 and 87500) provided on February 22, 2022. 
 
You asked the Plan to pay for the wound PCR panel. You say that this test was necessary and is covered by 
Medicare. The Plan denied your request. The Plan says this test was 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 pay for the wound PCR panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while the acquisition of a wound culture may have been reasonable, PCR 
testing/nucleic acid testing/molecular testing was not medically necessary or reasonable. In the absence of signs 
of infection or the presence of unusual organisms, such testing offered no benefit to standard wound cultures. 
 
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 wound PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the wound PCR (polymerase chain reaction) panel (87798, 87801, 87640, 87641 and 
87500) provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service February 15, 
2023. You asked the Plan to pay for the billed code. You say that the requested documents were provided. The Plan 
denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
The file shows that the services at issue were provided in an outpatient hospital facility. We find that payment 
for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 
99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for 
procedure code 99153 billed for date of service February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for pre-operative office visit examination and 
electrocardiogram provided on December 13, 2022. 
 
You asked the Plan to waive the coinsurance for pre-operative office visit examination and electrocardiogram. 
You say that you spoke with the office manager, and she stated the provider and facility are in-network with 
Independent Health. 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 54.42 
coinsurance for outpatient hospital services.  
 
You have been asked to pay 54.42 coinsurance for pre-operative office visit examination and 
electrocardiogram. This item/service falls within the outpatient hospital services 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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for pre-operative office visit examination and electrocardiogram 
provided on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99442 billed for date of service January 26, 
2023.  
 
You asked the Plan to pay for procedure code 99442. You say that medical records were provided. 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 99442 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99442 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99442 billed for date of service January 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ForeseeHome monitoring device (0379T). 
 
You asked the Plan to pre-approve a ForeseeHome monitoring device. You say that you would like the denial 
to be reversed and this service to be approved for the enrollee. The Plan denied your request. The Plan says this 
service is not covered under Medicare. 
 
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 a ForeseeHome monitoring device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has age related macular degeneration. 
There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested 
service. Our reviewer found that the record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. Our physician reviewer also found that the requested service is not recommended. 
 
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 ForeseeHome monitoring device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a ForeseeHome monitoring device (0379T).