Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 25600-54 billed for date of service February 4, 2023. 
 
You asked the Plan to pay for code 25600-54. You say that the medical records support payment of this code. 
The Plan denied your request. The Plan says code 25600-54 is not supported by the medical record. The 
records do not indicate restorative treatment was performed to support the billed code. Instead, code 29125 
should have been 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 25600 is Closed treatment of distal radial fracture (eg, 
Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when 
performed; without manipulation. 
 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 25600-54. Our reviewer says that code 25600-54 is not 
supported by the medical record. Our reviewer found the procedure report describes a splint application service 
applied by the nurse. In this case, the documentation does not support closed treatment of distal fracture, and 
there is a more appropriate code to report for 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 code 25600-54 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 25600-54 billed for date of service February 4, 2023.
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  IRF services are physically and medically necessary 
for the enrollee. You would like reconsideration based on the records submitted. The Plan denied your request. 
The Plan says the enrollee does not meet Medicare guidelines for admission to 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 that the complexity of the enrollees 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 have a need for 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Power Knees (and all related codes: L5828 + L5845 + L5848 + 
L5859 + L5856). 
 
You asked the Plan to pre-approve power knees. You say that the items are medically necessary. The Plan 
denied your request. The Plan says that the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that payment may be made for the replacement of a 
prosthetic device that is an artificial limb, or replacement part of a device if the ordering physician determines 
that the replacement device or part is necessary because of any of the following:  
1. A change in the physiological condition of the patient;  
2. An irreparable change in the condition of the device, or in a part of the device; or  
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be 
more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replace 
 
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 power knees. Our reviewer says that the 
items are medically necessary. Our physician reviewer found the exacerbation of the enrollee's spondylosis and 
weight change count as physiological change directly affecting her functional needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power knees have been met. Therefore, we decided that the Plan has to pre-
approve Power Knees (and all related codes: L5828 + L5845 + L5848 + L5859 + L5856).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard rechargeable battery (L9900). 
 
You asked the Plan to pre-approve a standard rechargeable battery. You say that the battery pack in question is 
bulging out of its case as well as cracking. You would like a replacement as your current battery is 
malfunctioning. The Plan denied your request. The Plan says the requested battery does not meet the 
requirements for approval. 
 The Plan must follow Medicare rules. Medicare rules say that battery packs and battery chargers are replaced 
every three years for reasonable use.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a standard rechargeable battery have not been met. The records show that the provider has 
requested a standard rechargeable battery. The records also show that you received a battery charger in May 
2022, which is within its reasonable use of three years.  Therefore, we decided that the Plan does not have to 
pre-approve a standard rechargeable battery (L9900).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93010 and 93010-76 x 2 billed for date of 
service March 28, 2023. 
 You asked the Plan to pay for procedure codes 93010 and 93010-76 x 2. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 93010 
and 93010-76 x 2 are bundled into payment for code 92960. 
 
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, we have confirmed that codes 
93010 and 93010-76 x 2 are column II codes to column I code 92960. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 93010 and 93010-76 x 2 
billed for date of service March 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93923-51 billed for date of service February 10, 2023. 
 
You asked the Plan to pay for code 93923-51. You say that this service was medically necessary. The Plan 
denied your request. The Plan says code 93923-51 is not supported by the medical record. 
 
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 93923 is Complete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, 3 or more levels. 
 
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 93923-51. Our reviewer says that code 93923 is not 
supported by the medical record. Our reviewer found the procedure report does not include documentation of 
Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels. This procedure 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 code 93923-51 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 93923-51 billed for date of service February 10, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient admission provided from February 25, 2023, to February 
27, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient admission. You say that the Emergency Medical Treatment and 
Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be 
stabilized and treated. You also say that you would like this claim to be reviewed for medical necessity. The 
Plan denied your request. The Plan says that this claim was not authorized. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient admission. Our reviewer says 
that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. Our reviewer also found that it was medically reasonable and necessary for 
these services to have been rendered by an OON provider. 
 
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 inpatient admission have been met. Therefore, we decided that the Plan has 
to pay for the inpatient admission provided from February 25, 2023, to February 27, 2023, by an out-of-
network (OON) provider.  
 
  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 laboratory services (84443, 84145) provided on July 25, 
2021, through July 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plans denial. The 
Plan denied your request. The Plan says there was insufficient information provided to review this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Review of the file shows that no medical records were provided for the services rendered. Without medical 
records, medical necessity is not supported. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (84443, 84145) provided on July 25, 2021, through July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care supplies. 
 
You asked the Plan to pre-approve wound care supplies. You say that you are requesting reconsideration with 
supporting records. The Plan denied your request. The Plan says you records do not show serial wound 
measurements over a 30-day period. Thus, it is not clear if you have failed an adequate trial of standard wound 
care. 
 
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 wound care supplies. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found According to the product website Matrion is a full thickness, decellularized placental 
membrane graft. There is inadequate evidence in the peer-reviewed medical literature to support the clinical effectiveness of this decellularized graft.  Further studies are required to conclusively establish if placental 
membrane allografts are superior to allogeneic skin substitutes. A review of the literature indicates additional 
research is needed to fully understand how the differences in placental-derived biomaterial source, preservation 
techniques, decellularization methods, design, forms, frequency of application, and how methods of 
administration influence clinical outcomes. Future studies are needed to compare the clinical outcomes 
associated with the application of decellularized and non-decellularized placental-derived biomaterials in 
wound management. There is insufficient evidence in the literature that decellularized Matrion is more 
beneficial than other skin substitutes therefore the Matrion request is not medically necessary per Social 
Security Act. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve wound care supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omeza Collagen Matrix (A2014). 
 
You asked the Plan to pre-approve Omeza Collagen Matrix. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 Omeza Collagen Matrix. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation indicates that per the wound clinic note dated August 15, 2023, all 
wounds are documented to have more than 50% granulation tissue and are "slowly contracting" with current 
wound care regimen. There is no specific clinical rationale provided for the use of this product. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Omeza Collagen Matrix have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Omeza Collagen Matrix (A2014).
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 the enrollee will need care once they are sent home.  
The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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: 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 the patient is not safe to be discharged home. The 
Plan denied your request. The Plan says the skilled nursing facility (SNF) services requested do not meet the 
requirements for approval. 
 
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: 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 the IRF care. You say that the IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF admission. 
 
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 intensive rehabilitation therapy nor do they require 
frequent physiatry oversight. 
 
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: 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 the enrollee needs the services in order to return 
home safely. The Plan denied your request. The Plan says the enrollees needs can be met at an alternative 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.