Persius/hicric huggingface dataset:
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 the requested IRF services are necessary because the 
enrollee is a great fall risk. You say the enrollee needs rehabilitative services that focus on preventing a fall and 
assist in making sure the enrollee can negotiate the transfer and activities of daily living without the threat of a 
fall. The Plan denied your request. The Plan says admission to an IRF is not medically 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up (D2950), pontic (D6245), and a retainer 
crown (D6752). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says your benefit for the pontic and retainer crown has already been 
exhausted. Core buildups are not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the pontic and retainer crown was exhausted with the Plan's approval of one pontic and 
one retainer crown. Additionally, the core buildup is not a covered benefit. Therefore, we decided that the Plan 
does not have to pre-approve a core build-up (D2950), pontic (D6245), and a retainer crown (D6752).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
April 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed codes are 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. 
 
We find that CPT code 96365 and 96366 is not supported in the medical record. The records show that the 
enrollee received outpatient intravenous insulin therapy. There is a more accurate code available to describe the 
services provided. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date 
of service April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services February 24, 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 K22.70 has an Excludes1 note in relation to C15.5. 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 February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823). 
 You asked the Plan to pre-approve a power wheelchair. 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 follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee is noted to be a 
functional household ambulator and has a wheeled walker for assistance with mobility. He is independent with 
mobility, transfers and performing daily activities. The enrollee is noted to be at risk for falling but he has a 
walker for assistance with mobility and is independent with mobility in his home. The request was primarily 
for community mobility. Additionally, the enrollee is noted to have full motor strength and it is not clear why 
he cannot use a manual wheelchair for mobility if he is at high risk for falling. Therefore, the group 2 power 
wheelchair is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair (K0823).
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 has completed their acute care course.  
The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 The complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a urinary tract infection and sepsis. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The patient 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 patient 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel billed for date of service March 15, 
2023, with codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 
87481, 87651 and 87653. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel billed for date of service March 15, 2023, with codes 87500, 87641, 87798, G0452, 87491, 
87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651 and 87653.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), 
provided on April 16, 2023. 
 
You asked the Plan to pay for the ambulance service. You say that you fell when you tried to sit on your bed. 
You say that your partner found you an hour later and called an ambulance. You also say that you declined the 
offer for transport because you felt safe and did not need to go to the hospital. The Plan denied your request. 
The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 16, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998), provided on April 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on December 17, 2022. 
 
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 coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care for the evaluation and 
management of a patient, requiring a comprehensive history, a comprehensive examination, and medical 
decision making of high complexity. 
 
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 physician services. Our reviewer says that the 
documentation does not support the billed services. Our reviewer found the records do not support a comprehensive history. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on December 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 3, 2022, to 
April 20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the referring provider asked for this claim to 
be paid as in-network. The Plan denied your request. The Plan says these services are not covered when 
provided OON. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 3, 
2022, to April 20, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Principal Care Management (PCM) Services (99426, 
99427) provided on March 16, 2023. 
 
You asked the Plan to pay for the Principal Care Management (PCM) Services (99426, 99427). You say that 
the services should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the Principal Care 
Management (PCM) Services (99426, 99427) provided on March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the code reported. 
 
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 93010 is: Electrocardiogram, routine ECG with at least 
12 leads; interpretation and report only. 
 
 We find that CPT code 93010 is not supported in the medical record. Specifically, a procedure report for the 
date of service at issue has not been provided for review. The billed code cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of procedure code 93010 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 93010 billed for date of service 
August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oxygen concentrator (E1390) and a portable gaseous oxygen 
system (E0431). 
 
You asked the Plan to pre-approve an oxygen concentrator and portable oxygen. You say that you disagree 
with the denial. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
approval of the requested devices. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an oxygen concentrator and portable 
oxygen. Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee has severe obesity, hypertension, heart failure with 
reduced ejection fraction (HFrEF), cirrhosis of the liver, and emphysema. A 6-minute walk test was performed 
during the visit on August 23, 2023. Resting oxygen saturation breathing room air was 93%, but saturation of 
peripheral oxygen (SpO2) dropped to 83% after the first minute of walking. This was corrected to 95 to 96% 
while on supplemental oxygen at 2 liter/minimum. This meets Medicare criteria for supplemental oxygen. The 
denial is reversed. 
 
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 oxygen concentrator and portable oxygen have been met. Therefore, we 
decided that the Plan has to pre-approve an oxygen concentrator (E1390) and a portable gaseous oxygen 
system (E0431).  
 
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 procedure codes 87150, 87481, 87641, 87653 and 87798 
billed for date of service January 23, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653 and 87798. You say that these 
services were necessary and are supported in the medical record. The Plan denied your request. The Plan says 
these codes are not supported for separate reporting or payment. 
 
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 87150, 87481, 87641, 87653 and 87798 are column II codes to 
column I codes 87500 and/or 87801; however, 87150, 87481, 87641, 87653 and 87798 were each billed with a 
modifier.  
 
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 procedure codes 87150, 87481, 87641, 87653 and 87798. 
Our reviewer says that these codes are not supported with the XU modifier for separate reporting. Our reviewer 
found the laboratory report does not include documentation to support that these were unusual non-overlapping 
services from the primary procedure(s). 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87641, 87653 and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653 and 
87798 billed for date of service January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 17, 2022, and 
December 8, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that you do not have input over what lab is used for lab 
work. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on November 17, 2022, 
and December 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one thoracic epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve three injections at the same time. You say that the injections are very much 
needed to proceed for pulmonary rehabilitation for your lower and upper back so you will be able to move 
around for exercise. The Plan denied your request. The Plan says the three injections at separate spinal regions 
should not and cannot be approved at the same visit. Two injections in one region have been approved and the 
remaining injection can be done safely at a later date. 
 
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 thoracic ESI. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the two lumbar ESIs in one region have 
been approved and the remaining thoracic ESI can be done safely at a later date. The review has determined 
that you do not meet the LCD criteria for the thoracic epidural steroid injection. 
 
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 thoracic ESI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve one thoracic epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 15, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U.  
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service March 15, 2023.