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

 
We decided that the Plan has to pre-approve radiation treatment and additional image guided radiation therapy 
(IGRT) (77014, G6017). 
 
You asked the Plan to pre-approve radiation treatment and additional IGRT. You say that the enrollee has 
ascites and with changes in his abdomen, it will be difficult to determine the pancreatic head on a daily basis 
without IGRT. The treatment is medically necessary.  The Plan denied your request. The Plan says that there is 
no good evidence the IGRT is safe or effective for the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiation treatment and additional 
IGRT. Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily 
image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows 
accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and 
thus allow reduction in the volume of normal tissues exposed to radiation. For radiation in the palliative setting, 
the use of IGRT is generally considered not medically necessary outside of a medically plausible rationale (i.e., 
prior radiation treatment, unusual anatomy). In this case, while the intent is palliative, the case records 
document the need for IGRT based on the enrollee developing ascites. With ascites, set-up based on external 
markers (i.e., tattoos) is less reliable due to changes in abdominal girth as well as shifting internal anatomy. 
Also, with bowel close to the target, IGRT will help reduce the bowel exposure in the setting of ascites. The 
decision is favorable as IGRT is an accepted standard of care for exceptional cases of palliative treatment that 
are difficult to set up. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation treatment and additional IGRT have been met. Therefore, we decided 
that the Plan has to pre-approve radiation treatment and additional image guided radiation therapy (IGRT) 
(77014, G6017).  
 
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 physician's services provided on November 13, 2022, and 
November 14, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says an appeal was submitted by the provider with no new medical records. 
Documentation submitted on appeal consists of duplicates of medical documents previously reviewed. The 
Plan says that the Plan has insufficient documentation to corroborate the services so they cannot confirm 
Medicare coverage has been met. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the physician's services have been met. 
Therefore, we decided that the Plan does not have to pay for physician's services provided on 
November 13, 2022, and November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 28, 2023 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays 2 or more genes in a patient 
in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so 1 HCPCS codes must be submitted for the panel.  
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes, and 
not one unit of one code as required by LCA A58120. 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 genetic testing provided on February 28, 2023
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223-AI billed for date of service April 10, 2023. 
 
You asked the Plan to pay for code 99223-AI. You say that you provided medical records to support the billing 
of this code. The Plan denied your request. The Plan says you billed this service with an incorrect Place of 
Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99223-AI have not been met. Therefore, we decided that the Plan does not have to pay for 
code 99223-AI billed for date of service April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87541, 87798, 87486, 87631, 87637) provided 
on April 3, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory pathogen panels with more than 5 
respiratory pathogens performed in the Part B outpatient setting are considered not medically necessary and are 
non-covered. 
 
We looked at the file and Medicare rules. The test at issue is a respiratory pathogen panel that tested for more 
than 5 pathogens. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87541, 87798, 
87486, 87631, 87637) provided on April 3, 2023.
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 has had multiple falls, needs more 
access to physicians or licensed professional, lives alone, has not moved on own, has to have assistance to get 
out of bed or walk to bathroom and needs to be monitored 24/7. The Plan denied your request. The Plan says 
the enrollee's records do not show complex medical and nursing needs nor complex rehabilitation needs which 
require the need to be seen by a rehabilitation physician. 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 the genetic testing provided on March 22, 2023, billed with 
codes 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 22, 2023, billed with codes 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 
81479, and 81238.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospitalization provided from July 29, 2022, to August 1, 
2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you would like the previous denial 
be overturned as the inpatient level of care was medically necessary. The Plan denied your request. The Plan 
says that while the provider documented an inpatient order estimating a length of stay greater than 2 midnights, 
the clinical notes do not support a reasonable expectation of a medically necessary inpatient stay extending 
beyond 2 midnights for a planned cardiac catheterization in a hemodynamically stable patient. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the order states that the patient was expected to be admitted for greater than 2 
midnights. Additionally, the patient presented "clammy" and lethargic with a recent screening test that showed 
a possible high risk right coronary artery lesion. Our reviewer found that this warranted evaluation for atypical 
angina, and that coupled with the patients history of paroxysmal atrial fibrillation and having a pacemaker 
there was reasonable concern for a more serious issue that required evaluation. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the inpatient hospitalization provided from July 29, 2022, to August 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vehicle lift and carrier for a power scooter (E1399). 
 
You asked the Plan to pre-approve a vehicle lift and carrier. You say that you need the carrier in order to get 
the scooter around. The Plan denied your request. The Plan says this item does not serve a purpose that is 
primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a vehicle lift and carrier for a power scooter (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport wheelchair. 
 
You asked the Plan to pre-approve a transport wheelchair.. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the enrollee has a wheelchair that is less than 5 years old. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover 
repair up to the cost of replacement (but not actual replacement) for medically necessary equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a transport wheelchair. have not been met. Specifically, there is no justification as to why the 
wheelchair requires replacement or whether the enrollee's power wheelchair could be repaired, and how much 
it would cost to repair the current wheelchair.  Therefore, we decided that the Plan does not have to pre-
approve a transport wheelchair.
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 the enrollee will require reconditioning 
and endurance building to achieve their optimal function and enable their best opportunity to successfully 
return to their prior level of function or to obtain their greatest new functional status. You also say the LTACH 
offers the best opportunity for the enrollee to regain function and that a lower level of care would jeopardize 
any chance for an optimal outcome. The Plan denied your request. The Plan says admission to an LTACH is 
not medically necessary.  
 
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 there is no documentation provided indicating the medical necessity for 
admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the enrollee meets the medical necessity 
requirements for this surgery. The Plan denied your request. The Plan says the enrollee has evidence of other 
pain generating fractures. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery is covered if certain criteria 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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found there is no trial of a back brace 
for fracture 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve T12 kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 provided on April 6, 2023. 
 
You asked the Plan to pay for procedure code 99222. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services. POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21. However, the documentation shows that 
the patient was in an observation status. Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. Therefore, we decided that the Plan does not have to pay for procedure code 99222 
provided on April 6, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from March 13, 2023, to  
March 23, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this provider type is not eligible in the Medicare program.  
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from March 13, 2023, to March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (E1399). 
 
You asked the Plan to pre-approve a power wheelchair. You say that your life is in danger. You say that you 
cannot use your arms well. You say that you have limited mobility, chronic obstructive pulmonary disease 
(COPD), and cannot walk more than five minutes at a time. The Plan denied your request. The Plan says the 
necessary evaluations for approval of any power operated vehicle have not been completed. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a power wheelchair have been met. 
The file does not include a physician order or documentation to support the medical necessity of the requested 
item. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes B4185, B4193, B4224, and B4220 provided 
from March 31, 2023, to April 5, 2023. 
 
You asked the Plan to pay for procedure codes B4185, B4193, B4224, and B4220. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid physician order for these specific codes. While there is a physician order in 
the medical records, it is not specific with regard to the specific items being ordered for the patient and it does 
not provide any codes for the items being ordered. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for procedure codes B4185, B4193, B4224, and B4220 provided from March 31, 2023, to April 5, 2023.