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

 
We decided that the Plan does not have to pay for orthotics (A5500, A5512) provided on April 21, 2023. 
 
You asked the Plan to pay for the orthotics. You say that these items were medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order for the supplies provided in this case. The order does not 
specify what footwear is to be provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
orthotics (A5500, A5512) provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 38792 billed for date of service April 13, 
2023. 
 You asked the Plan to pay for procedure code 38792. The Plan denied your request. The Plan says payment for 
code 38792 is bundled into payment for code 38900. 
 
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 code 38792 
is a column II code to column I code 38900. 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 code 38792 billed for date of 
service April 13, 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 you need rehabilitation before you go home. The 
Plan denied your request. The Plan says 1-13267871246  
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do 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 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 you 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: 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee continues to have a need for skilled therapy; however, the enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. 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: Favorable

 
We decided that the Plan has to pay for the services (99214) provided on May 3, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code 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 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, 
which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99214 is 
supported by the records provided. Our reviewer found that the history and exam describe sufficient data and 
the medical decision-making is of moderate complexity, this level of coding is supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the services (99214) provided on May 3, 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department (ED) services provided on May 12, 2023, 
billed with code 99285. 
 
You asked the Plan to pay for the ED services as billed. You say that it is felt that this was billed correctly.  
The Plan denied your request. The Plan says that code 99285 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 ED services as billed. Our reviewer says 
that the records support the billed code.  Our reviewer found the medical decision making in this case was of 
high complexity. There was review of a computed tomography scan, labs, and laceration repair. There is 
documentation of a medically appropriate history and exam, and the patient has several medical problems that 
are documented. 
 
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 ED services as billed have been met. Therefore, we decided that the Plan 
has to pay for the emergency department (ED) services provided on May 12, 2023, billed with code 99285.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for codes 96365 and 96366 for date of service April 3, 2023. 
 
You asked the Plan to pay for codes 96365 and 96366. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the submitted medical records indicate an encounter date of April 
28, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan states that the submitted medical records 
indicate an encounter date of April 28, 2023, and that the billed date of service of April 3, 2023, cannot be 
verified. However, the documentation submitted included medical records for an encounter from April 3, 2023. 
No other denial rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that 
the Plan has to pay for codes 96365 and 96366 for date of service April 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99348 for date of service May 12, 2023. 
 
You asked the Plan to pay for procedure code 99348. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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. The rules also say that when a patient has a 
bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the 
condition still exists on both sides), including for the encounter to treat the first side 
 
In this case, the CPT Code Manual definition of code 99348 is Home or residence visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
low level of medical decision making. When using total time on the date of the encounter for code selection, 30 
minutes must be met or exceeded. 
 
We find that CPT code 99348 is not supported in the medical record. Specifically, this code was billed with 
right side diagnosis I87.311 and left side diagnosis I87.312. These two diagnosis codes should not be billed 
together as there is an appropriate bilateral code that can be billed. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99348 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99348 for date of service May 12, 2023.
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. The Plan denied your request. The Plan says the records do not 
show you meet the guidelines for a skilled nursing facility admission. The Plan says care could be provided 
with home health services. 
 
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 you/The do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous (IV) insulin therapy (OIVIT) 
services provided on April 19, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication. 
 
We looked at the file and Medicare rules. Per Medicare rules, the requested OIVIT services are not medically reasonable and necessary, and therefore are not covered. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the outpatient intravenous (IV) insulin therapy (OIVIT) services provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99214) 
rendered on March 15, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99214-95 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that while the history appears 
appropriate for the chief complaint, there is no evidence of moderate medical decision-making, nor is 
documentation provided that 30-39 minutes of total time was spent on this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99214) rendered on March 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollee's needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found services can safely be provided at the current facility until the enrollee is more stable 
to transfer to another 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R73.9 has an Excludes1 note in relation to E11.65. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the services provided on May 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 billed for date of service March 3, 
2023. 
 You asked the Plan to pay for procedure code 99231. You say that this service is separately payable. The Plan 
denied your request. The Plan says payment for code 99231 is bundled into payment for code 01215. 
 
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 code 99231 
is a column II code to column I code 01215. 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 code 99231 billed for date of service March 3, 2023.
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 a panniculectomy. You say that a panniculectomy is medically necessary. 
The Plan denied your request. The Plan says the requested panniculectomy 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 a panniculectomy. Our reviewer says 
that the requested panniculectomy is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has a diagnosis of rectus diastasis and excess abdominal skin with 
reported symptoms of pain and skin rashes. Based on the medical records provided there is inadequate 
documentation that the panniculectomy at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. The provided records in this case do not document trial and failure of any conservative measures or pharmacotherapy of the enrollees symptoms with the rectus diastasis and excess 
abdominal skin with pain and skin rashes.  
 
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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code R0070 for date of service February 6, 2023. 
 
You asked the Plan to pay for code R0070. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as 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 R0070 is transportation of portable x-ray equipment and 
personnel to home or nursing home, per trip to facility or location, one patient seen. 
 
We find that CPT code R0070 is not supported in the medical record. Specifically, the file shows that this was 
the only service billed on this claim. This code is not payable without a related or qualifying service being 
approved. Based on this information, we decided that Medicare rules for coverage of code R0070 have not 
been met. Therefore, we decided that the Plan does not have to pay for code R0070 for date of service February 
6, 2023.