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 enrollee is very deconditioned and very weak and 
would benefit admitting to the IRF. The Plan denied your request. The Plan says an IRF stay is not supported 
based on the records received.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says criteria for admission to the LTACH have 
not been met.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate at 
this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interlaminar steroid injection provided on November 29, 
2022, by an OON provider.  
 
You asked the Plan to pay for an interlaminar steroid injection. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services are not authorized because the 
provider is out-of-network. 
  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 interlaminar steroid injection provided on 
November 29, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH level of care is the only 
option for a safe discharge due to the need for frequent nursing care, daily physician management, telemetry, 
daily laboratory tests, frequent vital signs, and physical, occupational and speech therapies. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare guidelines for admission to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0410 billed for dates of service February 1, 
2023, to February 16, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says an incorrect revenue code was billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0410 is group psychotherapy other than of a multiple-
family group, in a partial hospitalization setting, approximately 45 to 50 minutes. 
 
We find that CPT code G0410 was billed with revenue code 912. This code is not among those that are suitable 
for payment. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0410 billed for 
dates of service February 1, 2023, to February 16, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service September 20, 2022, to 
October 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that the final claim complies with billing guidelines. 
The Plan denied your request. The Plan says that the claim was billed with an invalid or missing value code 
with amount. 
 
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 looked at the file and the rules. We find that the claim was submitted with value codes with amounts. 
Based on this information, we decided that Medicare rules for coverage of the billed services have been met. 
Therefore, we decided that the Plan has to pay for the home health care billed for dates of service September 
20, 2022, to October 7, 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 the office visit provided on September 08, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the denied 
claim. 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 office visit provided 
on September 08, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64635 and 64636 billed for date of service 
March 23, 2023.  
 
You asked the Plan to pay for procedure codes 64635 and 64636. You say that the claim should be reprocessed 
and paid as a facility claim. The Plan denied your request. The Plan says the number of units billed for 
procedure code 64635 exceeds the maximum allowed. The Plan also says that procedure code 64636 is an add 
on code that was billed without a primary procedure code eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid 
when the MAI value is 2.  
 
In this case, the MUE for CPT code 64635 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. In addition, we have confirmed that code 64636 is an add-on code and has not been 
billed with an appropriate primary procedure code that is eligible for payment. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 64635 and 64636 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 64635 and 64636 billed for date of service 
March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Urine Wellness Panel (87551, 87481, 
87798) provided on March 24, 2023, and April 5, 2023.  
You asked the Plan to pay for the Comprehensive Urine Wellness Panel. The Plan denied your request. The 
Plan says this panel is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Comprehensive Urine Wellness Panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the Comprehensive Urine Wellness Panel (87551, 87481, 87798) provided on March 
24, 2023, and April 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 35701, 41150, 42415, 60200, 61590, and 
61605 rendered on January 17, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported by the medical records submitted. 
 
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: 
 
CPT 35701: 
 
Exploration not followed by surgical repair, artery; neck (eg, carotid, subclavian)  
CPT 41150: 
 
Glossectomy; composite procedure with resection floor of mouth and mandibular resection, without radical 
neck dissection 
 
CPT 42415: 
 
Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve 
 
CPT 60200: 
 
Excision of cyst or adenoma of thyroid, or transection of isthmus 
 
CPT 61590: 
 
Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline 
skull base, nasopharynx), with or without disarticulation of the mandible, including parotidectomy, craniotomy, 
decompression and/or mobilization of the facial nerve and/or petrous carotid artery 
 
CPT 61605: 
 
Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, 
petrous apex; extradural 
 
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 surgical report does 
not detail the performance of any of the denied codes. 
 
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 35701, 41150, 42415, 60200, 61590, and 61605 rendered on January 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 1, 2023, to March 
18, 202. 
 
You asked the Plan to pay for home health services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the provider is not under contract with the Plan and is not certified by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for home 
health services provided on March 1, 2023, to March 18, 202.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that delaying intense therapy will be detrimental to the 
enrollee. The Plan denied your request. The Plan says that the enrollee's condition does not meet Medicare 
guidelines for admission to 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the medical record overall significantly complies with the various documentation requirements for 
IRF admission. This enrollees condition is in fact complex and fragile. There is every reason to expect that the 
enrollee will participate in and benefit from services to include physical therapy, occupational therapy, speech 
language pathology/neuropsychology to assess for any actual durable loss of executive function, physician 
oversight of medications, cardiac, and neurological status, and case manager coordination of any additional 
services that might be needed to make a sustainable return home. 
 
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 
an 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group 1 standard power operated vehicle (POV) 
(mobility scooter) (K0800) purchased on September 27, 2022. 
 
You asked the Plan to pay for the mobility scooter. You say that the scooter is your lifeline as you are not able 
to stand or walk for more than a few minutes. You also say that doing things such as chores around the house, 
going in the yard, and going to family functions has become much easier with the use of the scooter. The Plan 
denied your request. The Plan says this request is not medically necessary. 
 
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.  
 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 mobility scooter. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found you have normal range of motion in 
your extremities and 5 out of 5 strength throughout. Our reviewer also found that there is no evidence that you 
cannot accomplish your MRADLs in the home with a walker or manual wheelchair. 
 
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 mobility scooter have not been met. Therefore, we decided that the Plan 
does not have to pay for the group 1 standard power operated vehicle (POV) (mobility scooter) (K0800) 
purchased on September 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has failed non-operative 
treatment. You also say that this is medically necessary for the enrollee. The Plan denied your request. The 
Plan says vertebrogenic pain is not a qualifying condition. The Plan also says that this 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 Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found additional study is needed to validate any benefit of the procedure, and to compare it to other interventions. The reviewer found that the provided records document facet arthrosis, disc 
bulging and other degenerative changes on spinal imaging which may be the cause of the enrollee's back pain. 
Therefore, the reviewer found that the requested Intracept procedure 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
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 admission to an IRF is necessary for you to 
recuperate. 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 your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you 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 you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for April 19, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99284 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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 these services. Our reviewer says that procedure code 99284 
is not supported. Our reviewer found the submitted records show that the enrollee's complaint was straightforward and the medical decision making involved was not of moderate complexity. As such, the billing 
of 99284 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99284 billed for April 19, 2023.