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

 
We decided that the Plan does not have to pay for physical therapy services (procedure code 97163) rendered 
on May 5, 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 records do not support the services 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 97163 is "Physical therapy evaluation: high complexity, 
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities 
that impact the plan of care; An examination of body systems using standardized tests and measures addressing 
a total of 4 or more elements from any of the following: body structures and functions, activity limitations, 
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or 
measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient 
and/or family." 
 
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 case pertains to an enrollee 
that was undergoing physical therapy for spinal stenosis. The history involves 2 personal factors/comorbidities 
that impact. The criterion for the code requires 3. 
 
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 physical therapy services (procedure code 97163) rendered on May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report and Hereditary 
Genetic Cardiac Test panel provided on May 15, 2023, and billed with codes 81225, 81226, 81227, 81231, 
81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238. 
 
You asked the Plan to pay for the GeneDose Genetic Response Report and Hereditary Genetic Cardiac Test 
panel. You say that this testing was medically necessary. The Plan denied your request. The Plan says this 
testing should be billed with single panel codes. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components.  
We looked at the file and Medicare rules. These tests were not billed with a single panel code as required. 
Based on this information, we decided that Medicare rules for coverage of the GeneDose Genetic Response 
Report and Hereditary Genetic Cardiac Test panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the GeneDose Genetic Response Report and Hereditary Genetic Cardiac Test panel 
provided on May 15, 2023, and billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 
81306, 81328, 81335, 81479, and 81238.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig (A9282) provided on February 17, 2023, through 
March 8, 2023. 
 
You asked the Plan to pay for the wig. You say that the item should be covered. The Plan denied your request. 
The Plan says this item was obtained through a provider that is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the wig (A9282) provided on February 
17, 2023, through March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99233) provided on June 27, 2023 to 
June 28, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 99233 is not supported in the medical record. Specifically, the records provided note 
the admit date and the date the records were dictated but do not note the date of service. Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99233) provided on June 27, 
2023 to June 28, 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 requires continuous nursing care, close 
physician oversight, physical therapy, and occupational therapy to maximize their potential to return to their 
previous level of independence. 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 the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional 
status.  The enrollee can receive further services at a lower 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing services provided from April 1, 2023, to April 30, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that code G0300 
must be submitted with revenue code 551. 
 
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. Code G0299 was correctly billed with revenue code 0551. The rules say 
that either code G0299 or G0300 may be billed with this revenue code. Code G0155 was correctly billed with 
revenue code 0561. 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 skilled nursing services provided 
from April 1, 2023, to April 30, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru DX urinary tract infection - antibiotic resistance 
molecular test panel provided May 1, 2023, billed with codes 87481-90-XU, 87798-90-XU x12, 87801-90 x3. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says the unbundling of 
lab codes for PCR panel testing is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. This was a 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 laboratory testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Altru DX urinary tract infection 
- antibiotic resistance molecular test panel provided May 1, 2023, billed with codes 87481-90-XU, 87798-90-
XU x12, 87801-90 x3.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block (64454), and ablation (64624). 
 
You asked the Plan to pre-approve the outpatient procedures. You say that the enrollee has not had a nerve 
block previously. You say that the enrollee has tried and failed conservative treatments. You also say that the 
enrollee should be allowed to have this done. The Plan denied your request. The Plan says the notes do not 
show that the enrollee has had a diagnostic nerve block. The Plan also says that the enrollee has not had a 
comprehensive evaluation with other medical specialists. 
 
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 outpatient procedures. Our reviewer 
says that the requested genicular nerve block and ablation are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested services are considered experimental as it is the subject of ongoing clinical trials. Therefore, the reviewer found that the requested genicular nerve blocks 
and ablation 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 outpatient procedures have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block (64454), and ablation (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve freestyle libre kit 2 sensor. 
 
You asked the Plan to pre-approve freestyle libre kit 2 sensor. You say that it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 freestyle libre kit 2 sensor. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the coverage criteria for continuous glucose monitoring (CGM) require 
insulin use or low blood group substance (BGS). The enrollee is not taking medicines that typically cause low 
BGS and the documentation has not mentioned the enrollee is having low BGS. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of freestyle libre kit 2 sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve freestyle libre kit 2 sensor.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscle test (95886) provided on February 7, 2023. 
 
You asked the Plan to pay for the testing. You say that medical records submitted support code 95886 and 
should be paid. The Plan denied your request. The Plan says CPT code 95886 was billed without an appropriate 
primary procedure code. Therefore, code 95886 is not supported. 
 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 95886 is an add-on code and has not been 
billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for the muscle test (95886) 
provided on February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 6, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 12, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 12, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided from October 18, 2022, to 
October 26, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the DRG originally billed. The Plan denied your request. The Plan says that the 
medical records do not support the DRG billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J95.1 (Acute pulmonary 
insufficiency following thoracic surgery). 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that the DRG originally billed was 
appropriate. Our physician reviewer found the enrollee with a history of coronary artery disease, chronic 
obstructive pulmonary disease (COPD), who underwent coronary artery bypass graft surgery (CABG) with 
aortic valve replacement. The enrollee was documented to require mechanical ventilation, then intermittent 
non-invasive positive pressure ventilation after extubation, therefore code J95.1 is supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided from October 18, 2022, to October 26, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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 procedure code 97750-GP billed for date of service April 25, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the billed code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that CPT code 97750-GP is not supported in the medical record. 
The records provided do not include a plan of care. 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 97750-GP billed for date of service April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says although there are three requested power options (tilt, recline and elevating 
leg rests), there is not a medical need to control these power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the patient's right upper extremity function 
is sufficient to control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ procedure (0775T). 
 
You asked the Plan to pre-approve the LinQ procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 LinQ procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding imaging or radiographic evidence 
supporting a sacroiliitis pathology. There is no clear history of sacroiliac (SI) joint pain onset or failure of 
conservative treatment directed to the SI joint. Multiple other plausible pain generators including at the 
lumbosacral spine are evident. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 LinQ procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the LinQ procedure (0775T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 21, 2022.