Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 is chronically deconditioned. She does not require complex or intensive 
rehabilitation. She does not 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: 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 does meet Centers for Medicare and 
Medicaid Services (CMS) IRF admission criteria, and their ongoing rehabilitation needs warrant an IRF level 
of care.  The Plan denied your request. The Plan says an IRF admission is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that she would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain her functional status.  The enrollee can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 failure to provide the ventilator may result 
in costly hospital readmissions, decline in overall health and ultimately a risk of harm to the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of the 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. 
 
 
 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 interstitial lung disease. 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 bilevel positive airway pressure (BiPAP) machine with average volume-assured 
pressure support (AVAPS) capability and failure of such a device has not been documented. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (NIV) (E0466). 
 
You asked the Plan to pre-approve an NIV. You say that the enrollee is high risk of harm if he does not use a 
noninvasive ventilator. The Plan denied your request. The Plan says the request for an NIV is not medically 
necessary because the documentation does not support that this device meets but does not exceed the enrollee's 
need. 
 
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. 
 
 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 an NIV. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
chronic hypoxic respiratory failure from chronic obstructive pulmonary disease. 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 bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
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 an NIV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a non-invasive ventilator (NIV) (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical stimulation device used for cancer 
treatment, includes all accessories (E0766x3 months). 
 
You asked the Plan to pre-approve an electrical stimulation device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria of the requested 
device. 
 
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 an electrical stimulation device. 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 
continued treatment with Optune at issue in this case meets all Medicare and LCD criteria for medically 
reasonable and necessary and is safe and effective for the enrollee. Provided records in this case do not 
document objective evidence of adherence to therapy, reviewed by the treating practitioner defined as the use 
of TTFT for an average of 18 hours per day (excluding days the treating practitioner has documented a medical 
need to limit or interrupt treatment) as required by the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical stimulation device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electrical stimulation device used for cancer treatment, includes all 
accessories (E0766x3 months).
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 inpatient rehabilitation facility is medically 
necessary. The Plan denied your request. The Plan says the enrollee's medical condition does not require 
physician evaluation and supervision three times a week.  
 
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 
has a history of osteoarthritis of the knees and is living at home with weakness and frequent falls. The 
enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0444 billed for date of service January 11, 
2023. 
 
You asked the Plan to pay for procedure code G0444. You say that this service should be covered. The Plan 
denied your request. The Plan says payment for code G0444 is bundled into payment for code 99214. 
 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 G0444 
is a column II code to column I code 99214. 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. Records show the 
deductible was not yet met, so the correct cost sharing was applied. Therefore, we decided that the Plan does 
not have to pay for procedure code G0444 billed for date of service January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve an office visit. You say that you would like the enrollee to see the same 
doctor. The Plan denied your request. The Plan says this service was not approved. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an oOON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99204) provided on March 3, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the claim history shows this 
patient is an established patient, with previous services provided by the same provider group. Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99204) provided on March 3, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 93010 billed with diagnosis 
codes R55 and I95.1 provided on February 1, 2023. 
 
You asked the Plan to pay for procedure codes 99291 and 93010. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 The Plan must follow Medicare rules. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes R55 and I95.1 should not be reported together. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99291 and 93010 billed with diagnosis codes R55 and I95.1 provided on 
February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service December 
27, 2022. 
 
You asked the Plan to pay for procedure code 87640. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 87640 is bundled into 
payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. 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 87640 billed for date of service December 27, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging, spinal 
canal, and contents (72148), and a Computed tomography, lower extremity (73700). 
 
You asked the Plan to pre-approve a Magnetic resonance imaging and a Computed tomography. You say that 
services are medically necessary for the enrollee. The Plan denied your request. The Plan says the guidelines 
require at least 6-weeks of physician- directed treatments with an initial visit and a follow-up visit to qualify for 
advanced imaging tests, the enrollee does not meet guideline requirements and the imaging studies. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Magnetic resonance imaging and a 
Computed tomography. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the medical necessity of the requested CT left ankle and MRI lumbar spine has not been established in 
this enrollee has been referred for physical therapy. 
 
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 Magnetic resonance imaging and a Computed tomography have not been met. Therefore, we decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging, 
spinal canal, and contents (72148), and a Computed tomography, lower extremity (73700).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar interbody fusion L4-L5 and related services.  
 
You asked the Plan to pre-approve lumbar interbody fusion L4-L5 and related services. You say that the 
records provided support the need for the surgery in dispute.  The Plan denied your request. The Plan says there 
is no slippage of the bones of the spine on the official imaging report. The Plan says that the enrollee has no 
symptoms reported related to nerve or spinal cord pressure that would require fusion.  
 
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 lumbar interbody fusion L4-L5 and 
related services. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no documented spinal instability.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar interbody fusion L4-L5 and related services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lumbar interbody fusion L4-L5 and related 
services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal cord stimulator replacement (63685) services. 
 
You asked the Plan to pre-approve spinal cord stimulator replacement services. You say that the records 
provided support the need for a spinal cord stimulator replacement.  The Plan denied your request. The Plan 
says the enrollee already has had a spinal cord stimulator placed in the past and that no documentation was 
provided to show that replacement of the device would improve the enrollee's symptoms.  
 
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 spinal cord stimulator replacement 
services. Our reviewer says that spinal cord stimulator replacement services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic back pain. The 
records indicates that the enrollee had a spinal cord stimulator placed in their back in 2019 and they initially 
had satisfactory pain relief. However, the degree of pain relief has decreased, and the request is for placement 
of a second spinal cord stimulator. The physician is requesting to change the enrollee's spinal nerve stimulator 
to a Medtronic device since recent lumbar injections have been ineffective. There is no documentation of 
malfunction of the current device, problems with the battery, or other reason to exchange the device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator replacement services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve spinal cord stimulator replacement (63685) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93613 and 93623 rendered on December 15, 
2022. 
 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 the records do not support the services 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. 
 
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 in terms of CPT 93613, when a 
NCCI Edit exists between procedures, an appropriate modifier should be appended. In this case, a modifier was 
not appended, and therefore claim was denied correctly. In terms of CPT 93623, the procedure report does not 
describe IV drug infusion. Although, CPT 93623 may be reported for IV drug infusion for diagnostic 
programmed stimulation and pacing, it should not be reported for injections of a drug with stimulation and 
pacing following an intracardiac ablation procedure (93653-93657) to confirm the adequacy of the ablation. 
 
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 procedure codes 93613 and 93623 rendered on December 15, 2022.