Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), inner liner (K0108), 
and bracket assembly footplate connector (K0108). 
 
You asked the Plan to pre-approve an electronic connection, inner liner, and bracket assembly footplate 
connector. The Plan denied your request. The Plan says the bracket assembly footplate connector (K0108) is 
duplicate for foot plates that already come with the power wheelchair, and there is no documentation as to why 
the requested additional foot plates are needed. There is no documentation that the inner liner is primarily 
medial in nature. The Plan also says that although there are two approved power options on this wheelchair (tilt 
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, inner liner, 
and bracket assembly footplate connector. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
sufficient strength and function in their upper extremities to manage standard power drives. There is no medical 
indication provided for the inner liner nor is the inner liner described. Our reviewer found that the medical 
necessity for the inner liner is not supported in the record. Our physician reviewer also found that the foot 
bracket assembly and connector is included in the wheelchair base and is not billable separately. 
 
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, inner liner, and bracket assembly footplate connector 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection 
(E2311), inner liner (K0108), and bracket assembly footplate connector (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87481, 87641, 87653, 87798) provided 
on January 25, 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 the documentation does not support the billed services. 
 
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 codes 87150, 87481, 87641, 87653, & 87798 is not supported in the medical record. 
Specifically, records were not provided to show that these services were separate from code 87801. The plan 
requested additional records and none were provided. 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 (87150, 87481, 87641, 87653, 87798) provided on January 25, 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 you do not want to go to a nursing home and require 
IRF services to get stronger. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 code G0483 for date of service December 12, 2022. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the submitted medical 
records do not indicate that 22 or more drug classes were ordered including the name of specific drug classes. 
Based on this information, we decided that Medicare rules for coverage of code G0483 have not been met. 
Therefore, we decided that the Plan does not have to pay for code G0483 for date of service December 12, 
2022.
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 1, 2022. 
 
You asked the Plan to pay for code 99233. You say that the medical records support the level of care billed. 
The Plan denied your request. The Plan says code 99233 is not supported by the medical record. The records 
don't support a detailed interval history or medical decision making of high complexity. 
 
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 care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high complexity.  
 
 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 is a 76-year-old woman with history of 
thrombocytopenia and myeloproliferative disorder who presented to the emergency room with lower extremity 
pain. In this case, the documentation supports a detailed exam, but not a detailed history or medical decision 
making of high complexity. 
 
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 1, 2022.
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 these services are medically necessary. The Plan 
denied your request. The Plan says the required services can be provided in an alternate setting.  
 
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. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies. 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from 
November 30, 2022, to December 22, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary. The 
Plan denied your request. The Plan says E0675 is not covered by Medicare. 
 
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 (E0675) provided from November 30, 2022, to December 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcranial doppler study of the intracranial arteries 
provided on March 28, 2023. 
 
You asked the Plan to pay for transcranial doppler study of the intracranial arteries. You say that transcranial 
doppler study of the intracranial arteries was medically necessary. The Plan denied your request. The Plan says 
transcranial doppler study of the intracranial arteries does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that transcranial doppler study of the intracranial arteries 
is covered when the criteria listed in the Medicare rules section of this decision 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 pay for transcranial doppler study of the intracranial 
arteries. Our reviewer says that the requested transcranial doppler study of the intracranial arteries is not 
considered medically reasonable and necessary in this case. Our physician reviewer found the documentation 
does not meet coverage criteria and does not support the medical necessity of the study in question. Evaluation 
of headache is not a covered indication for transcranial doppler. The provider notes in the appeal that the study 
was warranted to rule out cerebral aneurysm and embolic stroke, however the study provides no information 
with respect to the presence or absence of an aneurysm or a stroke.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcranial doppler study of the intracranial arteries have not been met. 
Therefore, we decided that the Plan does not have to pay for transcranial doppler study of the intracranial 
arteries provided on March 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone and cannot manage at this 
time. The Plan denied your request. The Plan says admission to a SNF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 this is medically necessary. The Plan denied your 
request. The Plan says this 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 On review of the available records, the enrollee with debility from acute illness as 
described above does not meet CMS coverage criteria for IRF admission. 
The enrollee is medically stable and does not need PMR physicians supervision 3 times a week in an IRF. 
 No acute rehab nursing needs identified or documented. 
At the current functional level, the enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. 
She will not tolerate the intensity of therapies in IRF and is unlikely to improve to become independent to 
return home alone. 
Document does not support necessity for admission to an IRF. The complexity of the enrollees medical, rehab, 
and nursing needs (combined complexity) does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. 
The enrollees rehab needs can be safely provided in an alternate and low intensity setting such as in an SNF.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the care requested is the medically 
appropriate level of care and the most optimal opportunity for a successful outcome for the enrollee. The Plan 
denied your request. The Plan says this request 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 the patient does not require services at the LTACH that are not already available at 
the current facility. There are no services at the LTACH that the patient requires that are not already available 
and covered at the current facility. Our reviewer also found that transfer to the LTACH is not medically 
necessary as the patient is not yet stable for transfer and as it would not be clinically advantageous at this time. 
Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on April 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 (G0483) provided on April 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 71275 performed on 
December 17, 2022. 
 
You asked the Plan to pay for the radiology services. You say that 71275 should be paid because it is supported 
in the documentation. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 31, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for the radiology services coded as 71275 performed 
on December 17, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that acute rehabilitation will benefit you by giving you 
more hours of physical and occupational therapy so you can reach your potential and get back to your baseline. 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall complies with the various documentation requirements for IRF admission. 
There is every reason to expect that you will participate in and benefit from physical and occupational therapy, 
physician oversight of your numerous medications and overlapping comorbidities, and case manager 
coordination of any additional services that might be needed to make a sustainable return home, as well as 
avoid preventable readmissions to the acute hospital. Therefore, the requested IRF admission is approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.