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 you are requesting reconsideration for the denial of 
an IRF admission. You say you are in need of 24-hour care at a rehabilitation center and not nursing home care.  
The Plan denied your request. The Plan says criteria for admission to the acute IRF setting have not been met.  
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. You say you recently underwent an amputation of your right leg and need to go 
to rehabilitation to be able to be independent again. The Plan denied your request. The Plan says the IRF 
services requested 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 not considered medically reasonable and necessary based on Medicare guidelines. 
Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission based on medical necessity. The Plan denied your request. The Plan says the 
IRF services requested 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the records should be reviewed for medical 
necessity. The Plan denied your request. The Plan says the services were billed with an incorrect code. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records show that more 
than 22 drug classes were tested. There is a more appropriate code available to describe the services provided.  
 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 G0482 billed for date of 
service October 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 9, 2022, to 
August 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that for home health services must be submitted with correct 
claim information. 
 
We reviewed the file and the Medicare rules. We find that the claim was billed with an invalid therapy and 
revenue code combination. The home health agency reported an occupational therapy HH discipline G0152 
with a physical therapy revenue code 042x which is not appropriate for the physical therapy revenue code 
reporting. Based on this information, we find that the Medicare rules for payment of the claim at issue have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
July 9, 2022, to August 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system (L5981), and multi-axial rotation 
unit (L5986). 
 
You asked the Plan to pre-approve the prosthetic components. You say that the requested components should 
be approved. The Plan denied your request. The Plan says the requested components 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 the prosthetic components. Our reviewer says that the requested prosthetic components are not considered medically reasonable and necessary 
in this case.  Our physician reviewer found the provided documentation does not support that the enrollee is a 
K3 ambulator. Therefore, the reviewer found that the requested components are 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 prosthetic components have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a flex-walk system (L5981), and multi-axial rotation unit (L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing-facility care (99305, 99308) and discharge-day 
management (99315) provided on dates of service from October 6, 2022, to November 18, 2022. 
 
You asked the Plan to pay for nursing-facility care and discharge. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a code also note instructs that two codes may 
be required to fully describe a condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of nursing-facility care and discharge have not been met. Specifically, the services at issue have been 
reported with primary diagnosis code S81.011A. Diagnosis code S81.011A has a "code also" note, meaning 
that an additional diagnosis code is required to indicate any associated conditions, in this case any associated 
wound infection. No diagnosis code for wound infection has been reported. Therefore, we decided that the Plan does not have to pay for nursing-facility care (99305, 99308) and discharge-day management (99315) provided 
on dates of service from October 6, 2022, to November 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service July 17, 
2022.  
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. 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 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service July 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service coded as 80053, 83735, 84100, G0471 
and P9603 provided December 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee missed to provide the insurance 
details at the time of the service visit. Later you received the insurance information and submitted the claim to 
the Plan. The Plan denied your request. The Plan says the claim was received after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until December 9, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory service coded as 80053, 83735, 84100, G0471 and 
P9603 provided December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
27, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code is payable. The Plan denied your 
request. The Plan says procedure code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service December 27, 2022.
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 January 1, 
2023 to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was ordered by a participating 
provider and was medically necessary. 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 procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023 to January 28, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code A4239 billed for date of service February 13, 2023. 
 
You asked the Plan to pay for the billed services. You say that this is a valid code.  The Plan denied your 
request. The Plan says that the service is always bundled into payment for other services.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code A4239 is supported. Specifically, the code is payable under the durable medical 
equipment fee schedule. The claim does not indicate that the services were billed or provided by a physician. 
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 procedure code A4239 billed for date of service February 13, 
2023.  
 
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 placement of the Minuteman device.  
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this should be allowed as it would 
be beneficial.  The Plan denied your request. The Plan says this is not covered when performed as a standalone 
procedure.  
 
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 Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found the Minuteman device is experimental. More research is needed to support 
medical necessity.  
 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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the Minuteman device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you are requesting reconsideration of the 
denied power wheelchair. The Plan denied your request. The Plan says the requested power wheelchair 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 pre-approve a power wheelchair. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that the record does not support your 
mobility needs cannot be met with a device other than a power 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 a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair (K0823).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service November 
10, 2022.  
 You asked the Plan to pay for the billed service. You say that the diagnosis code was billed correctly.  The Plan 
denied your request. The Plan says an acceptable primary diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99223 was billed with primary diagnosis code R65.21. This diagnosis code has a code 
first notation indicating it is not permitted to be used as a primary diagnosis code. Based on this information, 
we decided that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99223 billed for date of service November 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device (K1018) and accessories (K1019). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that you have essential tremor which is 
embarrassing for you. You say that you have tried betablockers. You say that you do not like the side effects. 
You also say that you would like for this to be approved. 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 a Cala Trio device. Our reviewer says 
that the requested Cala Trio device is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the requested device is not proven to have long term effectiveness for the enrollee's 
condition. Therefore, the reviewer found that the Cala Trio device 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 a Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device (K1018) and accessories (K1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foldable power wheelchair. 
 
You asked the Plan to pre-approve a foldable power wheelchair. You say that you want the Plan to cover this 
item. The Plan denied your request. The Plan says there is no documentation to support that a foldable power 
wheelchair for community mobility is medically necessary 
 
The Plan follows Medicare rules. Medicare rules say that specific criteria must be met for coverage of a power 
wheelchair. 
   
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 foldable power wheelchair. Our 
reviewer says that the requested item is not medically necessary. Our physician reviewer found the 
documentation available for review does not indicate that you require a power mobility device for mobility 
related self-care tasks in the 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 foldable power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a foldable power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on September 20, 
2022.  
 
You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary for 
this enrollee with a high risk of deep vein thrombosis.  The Plan denied your request. The Plan says this is not 
covered.  
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device provided on September 20, 2022.