Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6212 and A6199 billed for date of service 
December 27, 2022. 
 You asked the Plan to pay for procedure codes A6212 and A6199. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes A6212 and A6199 are not payable. 
 
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 codes A6212 and A6199 have a status indicator of P on the Physician Fee Schedule. 
These items were covered as other than incident to a physician service. This means that procedure codes A6212 
and A6199 are not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes A6212 and A6199 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes A6212 and A6199 billed for date of service December 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal tract imaging (91110). 
 
You asked the Plan to pre-approve a gastrointestinal tract imaging. You say that you believe this service is 
required. The Plan denied your request. The Plan says this request 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 a gastrointestinal tract imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has iron deficiency anemia in the 
setting of frequent blood donation. The record indicates that colonoscopy demonstrated a tubular adenoma.  
Our reviewer found that the record does not include follow up laboratory studies after the cessation of blood 
donation or treatment of the iron deficiency.  The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service at this time. Our physician reviewer also 
found that the elements of the coverage criteria are not satisfied, and the requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a gastrointestinal tract imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a gastrointestinal tract imaging (91110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found prostatic arterial embolization (PAE) is 
considered an experimental technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited 
studies have demonstrated possible short-term safety and efficacy.  The most recent American Urological 
Association (AUA) guidelines do not recommend this procedure outside of a clinical trial setting. The services 
are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prostate artery embolization (PAE).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetes self-management training provided on October 1, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for diabetes self-management training. You say that this is supported in the records. 
The Plan denied your request. The Plan says this was not authorized. 
 
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 diabetes self-management training provided on 
October 1, 2022, by an out-of-network (OON) provider.
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 you are appealing the denial for IRF. The Plan 
denied your request. The Plan says that the enrollee does not meet Medicare guidelines for services in an 
inpatient rehabilitation facility. 
 
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 enrollee's nursing, rehab, and medical needs (combined 
complexity) does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitative care. The enrollee does not need specialized and intensive therapies consisting of at least 3 hours 
of therapy per day at least 5 days per week. While the enrollee may benefit from physical therapy and 
occupational therapy, the enrollee's rehab needs can be provided in a lower intensity and alternate setting, such 
as in a skilled nursing facility. The enrollee does not meet CMS coverage criteria for IRF admission. 
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service October 14, 2022. 
 
You asked the Plan to pay for code 99233. You say that the medical records were supplied to support payment. 
The Plan denied your request. The Plan says code 99233 is not supported by the medical record for date of 
service October 14, 2022. The Plan contends that no medical records for the patient and the billed date of 
service were received. 
 
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 99233 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 high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 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 code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found  the enrollee was a then 69 year old female with a history 
of Multiple myeloma, and diabetes mellitus on an insulin pump who was admitted with Shingles for IV 
Acyclovir. The documentation submitted did not include documentation of 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 high level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac contractility modulation (CCM) therapy using 
the optimizer system implantable pulse generator (IPG). 
 
You asked the Plan to pre-approve CCM therapy. You say that the enrollee has tried all cardiac medicines and 
none of them are helping. You say that this device will allow the enrollee more independence and return to 
their quality of life. You also say that this is the enrollee's last resort for a better quality of life. The Plan denied 
your request. The Plan says the requested device 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 CCM therapy. Our reviewer says that 
the requested CCM therapy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. Therefore, the reviewer found 
that the requested CCM system 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 CCM therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cardiac contractility modulation (CCM) therapy using the optimizer system implantable 
pulse generator (IPG).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser enucleation of the prostate to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve laser enucleation of the prostate to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
laser enucleation of the prostate to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift incorporated lift chair (E0627). 
 
You asked the Plan to pre-approve a seat lift. You say that the enrollee needs the requested seat lift and medical 
records have been submitted. The Plan denied your request. The Plan says the requested item is considered not 
reasonable and necessary in the treatment of your chronic obstructive pulmonary disease (COPD). 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 seat lift. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found according to Medicare, a seat lift mechanism 
is covered if an enrollee has severe arthritis of the hip or knee or has a severe neuromuscular disease. The seat 
lift mechanism must be a part of the treating practitioners course of treatment and be prescribed to effect 
improvement, or arrest or retard deterioration of the enrollee's condition. Additionally, the enrollee must be 
completely incapable of standing up from a regular armchair or any chair in their home. Once standing, the 
enrollee must have the ability to ambulate. In this case, the documentation doesnt indicate that the enrollee has 
severe neuromuscular disease or that they are incapable of standing up from a regular armchair or any chair in 
their 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 a seat lift have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a seat lift incorporated lift chair (E0627).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service February 8, 
2023. 
 You asked the Plan to pay for procedure code 81345. You say that this service was medically necessary. 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 February 8, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 for date of service August 14, 2022. 
 
You asked the Plan to pay for procedure code 99221. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 99221 is not supported in the medical record. Specifically, this service was billed 
within the global surgery period for code 56405. Without an appropriate modifier, this means code 99221 is not 
separately payable from code 56405. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99221 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99221 for date of service August 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  laboratory services with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve  the OON laboratory services. You say that the multiple myeloma lab work 
is being requested to be done at the OON facility because of the laboratories specific and unique experience in 
this testing, specifically for multiple myeloma. You say that the attending physician is intimately involved with 
the laboratory to assure interpretation is being conducted appropriately.  The Plan denied your request. The 
Plan says it is not medically necessary for the enrollee to use a non-participating laboratory.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 OON laboratory services. Our 
reviewer says that the criteria for coverage of OON care have not been met.  Our physician reviewer found the 
Plans denial is medically justified on the basis that it is offering adequate care to meet your medical needs 
through referral to a network laboratory. There is nothing unique about your condition that would make it 
medically necessary to see the requested OON provider. The labs being requested are standard and don't 
require a special center to be done.  
 
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 OON laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve  laboratory services with an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve joint surgery (23472, 23430). 
 
You asked the Plan to pre-approve joint surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 joint surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found no compelling rationale is presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested total shoulder replacement, in this case, 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 joint surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve joint surgery (23472, 23430).