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

 
We decided that the Plan does not have to pre-approve acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee is in pain. The Plan 
denied your request. The Plan says the documentation does not support an expectation that the enrollee will 
require a greater than 2 midnight hospital stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this 
case. Our physician reviewer found the record does not show that an admitting physician would reasonably 
expect the enrollee's necessary hospital care will span at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital level of care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service December 7, 
2022, to December 26, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that continued care was provided to the enrollee. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service December 7, 2022, to December 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99203 and 93970 billed for date of service 
January 19, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
 We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on January 28, 2022. A comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed services were provided twice on the same date. Based on this information, 
we decided that the Medicare rules for the billed services have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 99203 and 93970 billed for date of service January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the inpatient rehabilitation facility (IRF) 
services you are requesting 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee is medically stable at the time of admission to participate in rehab but needs medical 
monitoring by PMR physician's supervision 3 times a week in an IRF. At the current functional level, the 
enrollee needs intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that after your surgery you require SNF services for 
therapy and wound care. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have 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 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that the requested scooter is medically necessary. The 
Plan denied your request. The Plan says you do not meet Medicare requirements for the requested PMD 
scooter, and this cannot be approved as your home is not accessible for the requested PMD and cannot be used 
solely for community use. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your 
condition can be improved by a walker, cane, or manual wheelchair. The records show that you can use a 
walker or a cane and that you have the strength to push a non-powered wheelchair. This means that Medicare 
rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds 
(K0800).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne Liquid CDx (0239U) provided June 27, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the FoundationOne Liquid CDx is a 
medically necessary laboratory test for patients with advanced stage solid tumor cancers who have decided to 
seek further treatment. The Plan denied your request. The Plan says that this service is not covered. this service 
does not meet medically necessary requirements. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has diffuse large cell B lymphoma. FoundationOne Heme 
is a laboratory developed test for blood cancers like leukemia and lymphoma, and for sarcomas, that tests over 
400 genes and biomarkers to identify targeted therapy, immunotherapy, or clinical trial options. The review has 
determined that the items/services at issue in this case are medically reasonable and 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 the laboratory service have been met. Therefore, we decided that the Plan has to 
pay for FoundationOne Liquid CDx (0239U) provided June 27, 2022.  
 
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 initial hospital care (procedure code 99222) rendered on 
August 30, 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 documents do not support this level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit." 
 
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 the provided records in this case 
do not document a chief complaint, an extended history of present illness, a review of all additional body 
systems and a complete past, family, and social history. Therefore, the records do not support a comprehensive 
history. Additionally, the records do not support a comprehensive examination, as the provided records in this 
case do not document a general multisystem examination or a complete examination of a single organ system. 
 
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 initial hospital care (procedure code 99222) rendered on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the infrared therapy (97026) provided from 
August 9, 2022, to August 30, 2022. 
 
You asked the Plan to reimburse you for the infrared therapy. You say that you paid $675 for these services. 
You also say that this was a lot of money for a service that tried to address your chronic pain. The Plan denied 
your request. The Plan says infrared therapy is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to reimburse you for the infrared therapy (97026) provided from August 9, 2022, to 
August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service 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 the Intracept procedure. Our reviewer 
says that the requested procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of back pain in this enrollee is unclear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
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 medically necessary for you to 
receive the care needed. The Plan denied your request. The Plan says the services are 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96374, 96375 and 99152 billed for date of 
service June 8, 2022. 
 
You asked the Plan to pay for procedure codes 96374, 96375 and 99152. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says these services are not supported 
for separate 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 96374, 96375 and 99152 are each column II codes to column I code 
20552; however, 96374, 96375 and 99152 were all 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 96374, 96375 and 99152. Our reviewer says 
that the documentation does not support the codes in question as separately identifiable procedures. Our 
reviewer found that the documentation is missing the key elements of moderate sedation, including an 
independent trained observer and the time spent at the patient's bedside performing moderate sedation. 
Therefore, code 99152 is not supported. In addition, the 59 modifier is not supported for separate payment of 
codes 96374 and 96375 as the documentation does not verify who administered the Toradol or the site of the 
injection, and the remaining medications were given as part of the procedure and cannot be reported separately. 
 
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 96374, 96375 and 99152 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 96374, 96375 and 99152 billed for date of 
service June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Calreticulin Exon 9 mutation detection, Jak2 Exon 
12 mutation analysis, MPL mutation analysis, and CSF3R testing. 
 You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says further testing is not yet indicated. 
 
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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has had mild thrombocytosis since 2016 with a negative work-up at that time, including 
a bone marrow biopsy, JAK2 and CALR. The platelets are mild elevated, and none are provided after 2021. 
There is no rationale given why repeat testing is warranted. The service is not reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Calreticulin Exon 9 mutation detection, Jak2 Exon 12 mutation analysis, MPL mutation 
analysis, and CSF3R testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventive procedure, by report (D1999) and 
bone replacement graft for ridge preservation - per site (D7953) provided on October 10, 2022. 
 
You asked the Plan to pay for dental services. You say that your insurance has unlimited coverage for dental 
implants. The Plan denied your request. The Plan says these services are not covered under your Plan. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Unspecified preventive 
procedure, by report (D1999) and bone replacement graft for ridge preservation - per site (D7953) are not 
covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D1999 and D7953 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
unspecified preventive procedure, by report (D1999) and bone replacement graft for ridge preservation - per 
site (D7953) provided on October 10, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the left hand. 
 
You asked the Plan to pre-approve the MRI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the request for an MRI is not medically necessary at this time. 
 
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 the MRI. Our reviewer says that the 
request is medically necessary. Our physician reviewer found that the documentation shows the enrollee has 
tenderness, crepitus, effusion and left palmar mass. A plain x-ray would not be necessary to evaluate these 
physical findings. The presence of these red flag signs makes the request for an MRI 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 the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
an MRI of the left hand.  
 
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.