Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99232 for date of service May 
27, 2023, to June 6, 2023. 
 
You asked the Plan to pay for procedure codes 99223 and 99232. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 The CPT Code Manual definition of code 99232 is subsequent hospital inpatient or observation care, per day, 
for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
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 99223 and 99232. Our reviewer says that 
the documentation does not support the codes billed. Our reviewer found the medical records do not document 
two out of three of an extensive number of diagnoses or management options, an extensive amount and 
complexity of data reviewed and high risk of complication. In addition, the documentation does not support 75 
minutes was met or exceeded. Therefore, code 99223 is not supported for date of service May 27, 2023. The 
medical records do not document 2 out of 3 of multiple diagnoses or management options, a moderate amount 
and complexity of data reviewed and moderate risk of complication. In addition, the documentation does not 
support that 35 minutes were met or exceeded. Therefore, code 99232 is not supported for dates of service May 
28, 2023, to June 6, 2023. 
 
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 99223 and 99232 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99223 and 99232 for date of service May 27, 2023, to 
June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that percutaneous vertebral 
augmentation is medically necessary. The Plan denied your request. The Plan says percutaneous vertebral 
augmentation does not meet the Medicare coverage criteria. The member has a confirmed, chronic fracture. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is covered when 
the criteria listed in the rules section of this decision 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 percutaneous vertebral augmentation. 
Our reviewer says that the requested percutaneous vertebral augmentation is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the medical records do not contain 
imaging studies that show a recent vertebral fracture that is less than 6-12 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
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 needs therapy in an inpatient setting to 
fully recover and regain maximum strength. The Plan denied your request. The Plan says the request for 
inpatient rehabilitation facility services does not meet the requirements for medical necessity.  
 
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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve CGM. You say that you need a CGM before leaving the hospital. The Plan 
denied your request. The Plan says you do not meet criteria for a CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 CGM. Our reviewer says that you do 
not meet criteria for a CGM. Our physician reviewer found the record does not indicate that you are being 
treated with insulin or have problematic hypoglycemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (A6250, A9286, and A4927).  
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the items are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable. Medicare rules also say that creams, salves, lotions, barriers (liquid, spray, wipes, powder, paste) or other skin care products (A6250) are not covered. The rules 
also say that non-sterile gloves are not covered because they are hygienic items that are non-reusable. 
 
The requested items (A6250, A9286, and A4927) are to be used as incontinence supplies. While incontinence 
supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. 
Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (A6250, A9286, and 
A4927).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (36415) provided on October 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 36415 is "Collection of venous blood by venipuncture". 
 
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 36415 is 
not supported by the records provided. Our reviewer found that the laboratory report describes "urine collection 
for urine culture". Code 36415 "is for all routine venipunctures, not requiring the skill of a physician, for 
specimen collection. This includes all venipunctures performed on superficial peripheral veins of the upper and lower extremities". This procedure is not supported in the documentation submitted. 
 
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 the services (36415) provided on October 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right-knee treatment with Orthovisc (J7324). 
 You asked the Plan to pre-approve right-knee treatment with Orthovisc. You say that the requested treatment is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested treatment 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 right-knee treatment with Orthovisc. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is no radiologic evidence of osteoarthritis of the right knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right-knee treatment with Orthovisc have not been met. Therefore, we decided 
that the Plan does not have to pre-approve right-knee treatment with Orthovisc (J7324).
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 the 
enrollee's medical management and rehabilitation needs that require an inpatient rehabilitation stay and close 
physician supervision. The Plan denied your request. The Plan says the enrollee does 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 enrollee does 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: 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 requires intensive inpatient rehabilitation 
with daily physician management, 24 hour specialized rehabilitation nursing, and intensive therapies to 
optimize mobility and strengthening while ensuring the restoration of functional status for a safe and 
sustainable discharge. The Plan denied your request. The Plan says the enrollee's condition does not meet the 
Medicare guidelines.  The Plan says that the services needed may be provided safely in a lower level of care.  
 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.  
 
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 pathology services (88305) provided on December 16, 2022. 
 
You asked the Plan to pay for pathology services. You say that these services were necessary and were reported 
appropriately. 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 D12.2 has an Excludes1 note in relation to K63.5. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for pathology services have not been met. Therefore, we decided that the Plan does not have to pay for 
pathology services (88305) provided on December 16, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes Q0092 and R0070 rendered on April 28, 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 that Healthcare Common Procedure Coding System (HCPCS) codes Q0092 and R0070 remain 
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 
the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) Q0092: 
 
Set-up portable x-ray equipment 
 
HCPCS R0070: 
 
Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or 
location, one patient seen 
 
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 supported by the medical records. Our reviewer found that the order shows the address of service 
to be the enrollee's home. The addendum issued later documents the transportation and setup of portable 
equipment. 
 
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 
procedure codes Q0092 and R0070 rendered on April 28, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624) and injection (64640). 
 
You asked the Plan to pre-approve nerve block. You say that the enrollee has failed all conservative 
management routine. You also say that this therapy is reasonable and necessary for the enrollee's condition. 
The Plan denied your request. The Plan says this type of injection is considered experimental /investigational 
and therefore cannot be covered. 
 
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 nerve block. Our reviewer says that the 
requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. Therefore, the reviewer found that the requested genicular nerve block for the left knee is 
not medically reasonable or 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64624) and injection (64640).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (97606) provided on February 17, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 97606 is "Negative pressure wound therapy (eg, vacuum 
assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), 
wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 
square centimeters". 
 
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 97606 is not supported by the records provided. Our reviewer found that this code is for a wound greater than 50 sq cm. 
The record states the wound vac was applied to a 26 cm closed wound. There is a more specific code for this 
size wound treatment. 
 
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 the services (97606) provided on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Envisia testing provided on April 30, 2023. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Envisia testing is covered for the indications 
established in the applicable LCD. 
 
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 testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee is a 70-year-old female with interstitial lung disease with biopsy showing no malignancy. Prior to the 
biopsy, computed tomography (CT) scans from February 2023 and March 2023 showed a lung nodule. Envisia 
genetic testing was provided. However, the LCD criteria are not met as the provided records do not clearly 
describe autoimmune disease having been ruled out with history and testing. 
 
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 pay for the Envisia testing provided on April 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is considered experimental. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient or that this device will increase participation in bimanual activities. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).