Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occupational therapy (OT) evaluation for driving. 
 
You asked the Plan to pre-approve the OT evaluation. You say that the services are medically necessary. The 
Plan denied your request. The Plan says Medicare does not cover services performed solely to assess a 
member's ability to drive. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 OT evaluation. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you are requesting authorization for occupational therapy to assess 
your ability to drive. There is no documentation of a recent injury or decline in function. The requested therapy 
does not serve a medical purpose and therefore cannot be 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 the OT evaluation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an occupational therapy (OT) evaluation for driving.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (U0005 and U0003) provided on July 8, 
2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says this claim was submitted with an 
inappropriate primary diagnosis. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. There 
are rules for reporting and sequencing sequela diagnosis codes.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, B94.8 (sequelae of other specified infectious 
and parasitic diseases) was reported as the primary diagnosis. However, this code was not expanded (to fourth, 
fifth or sixth character levels) to include the manifestation, and this code has not been preceded by a 
manifestation code or followed by a manifestation code identified in the Tabular List and title. Therefore, we 
decided that the Plan does not have to pay for laboratory services (U0005 and U0003) provided on July 8, 
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 you want to return to being independent. The Plan 
denied your request. The Plan says the services you need can be provided safely in other settings. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36556 billed for November 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 36556 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. 
 
We find that CPT code 36556 is not supported in the medical record. Specifically, there is no documentation of 
an insertion of a non-tunneled centrally inserted central venous catheter. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 36556 billed for November 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation (0055T). 
 
You asked the Plan to pre-approve computer-assisted surgical navigation. You say that this is medically 
necessary. The Plan denied your request. The Plan says medical studies haven't proven the use of this technique 
is helpful with this surgery. 
 
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 computer-assisted surgical navigation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there are no large volume, long-term/high-quality clinical studies that 
confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-
assisted surgery over standard surgical approaches in total shoulder arthroplasty. No compelling rationale is 
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 computer-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer-assisted surgical navigation (0055T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from August 19, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from August 19, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from August 
19, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of August 19, 2023, forward.  Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond August 19, 2023, as he 
was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from August 19, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 19, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4421 and A4222 billed for date of service 
January 20, 2023. 
 
You asked the Plan to pay for procedure code A4421 and A4222. You say that please reprocess the claim for 
payment. The Plan denied your request. The Plan says procedure code A4421 and A4222 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 A4421 and A4222 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code A4421 and A4222 is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4421 and A4222 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code A4421 and A4222 billed for date of service 
January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 provided on March 8, 2023. 
 
You asked the Plan to pay for procedure code 99204. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for procedure code 99204 is included in the global surgery 
payment for procedure code 27096 provided on March 8, 2023. Separate payment cannot be made for 
procedure code 99204. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99204 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99204 provided on March 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular pathology hereditary hemochromatosis DNA 
mutation analysis. 
 
You asked the Plan to pre-approve molecular pathology hereditary hemochromatosis DNA mutation analysis. 
You say that molecular pathology hereditary hemochromatosis DNA mutation analysis is medically necessary 
to obtain baseline in the event of a future veno occlusive crisis or other sickle cell related complication. The 
Plan denied your request. The Plan says this test is not standard of care. Records show hemoglobin sickle cell 
disease. No documentation was provided showing that there was clinically significant iron overload. Note that 
iron overload is a common complication of sickle cell disease and requires treatment based on the presence or absence of end-organ iron deposition or degree of ferritin elevation. The presence or absence of a hereditary 
hemochromatosis mutation would not change those treatment recommendations 
 
The Plan follows Medicare rules. Medicare rules say that approve molecular pathology hereditary 
hemochromatosis DNA mutation analysis 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 pre-approve molecular pathology hereditary 
hemochromatosis DNA mutation analysis. Our reviewer says that the requested molecular pathology hereditary 
hemochromatosis DNA mutation analysis is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the documentation does not show the enrollee with iron overload 
(high ferritin, etc.) to meet the Medicare LCD criteria for this testing. Baseline testing is not automatically 
covered as it would not change treatment at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of molecular pathology hereditary hemochromatosis DNA mutation analysis have 
not been met. Therefore, we decided that the Plan does not have to pre-approve molecular pathology hereditary 
hemochromatosis DNA mutation analysis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home ventilator (E0466).

You asked the Plan to pay for the home ventilator. You say that the item is medically necessary. The Plan
denied your request. The Plan says the item is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as
not reasonable and 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 pay for the home ventilator. Our reviewer says that
the enrollee does not need this item. Our physician reviewer found the records provided document that the
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode which
is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a
back-up rate.

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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pay for the home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 rendered on January 26, 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 Current Procedural Terminology (CPT) code 99213-25 remains 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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
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 records do not reflect an 
appropriate history or physical exam for this knee injection for knee pain. 
 
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 procedure code 99213 rendered on January 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of extracranial arteries; complete bilateral 
study (93880) and a rhythm electrocardiogram (ECG) (93040) provided on February 14, 2023. 
 
You asked the Plan to pay for a duplex scan of extracranial arteries. You say that you have submitted medical 
records for review of the denied codes on the claim. The Plan denied your request. The Plan says the submitted 
medical records do not indicate that a duplex scan of extracranial arteries was performed on the billed date of 
service The Plan also says payment for code 93040 is bundled into payment for code 93306. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 93040 is a column II code to column I code 93306. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
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 a duplex scan of extracranial arteries. Our reviewer says that 
the service is not medically necessary. Our reviewer found the documentation submitted was reviewed and 
does not meet criteria. Documentation submitted did not include a procedure report of duplex scan of 
extracranial arteries; complete bilateral to verify a complete test was performed. To cite the report, "Carotid 
Ultrasound: Study Preformed: Duplex scan of extracranial arteries; complete bilateral study. Technique: The 
study consisted of bilateral duplex doppler ultrasonography of the extracranial cerebral vasculature with color 
augmentation as well as spectral analysis with estimates of average peak systolic and mean end diastolic flow 
velocities. Conclusion: Moderate bilateral plaque on the bulbs". In this case, criteria for a complete study 
cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pay for a duplex scan of extracranial arteries; complete bilateral study (93880) 
and a rhythm electrocardiogram (ECG) (93040) provided on February 14, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for mobile cardiovascular telemetry services coded as 93229 for date of 
service February 2, 2023. 
 
You asked the Plan to pay for 93229. You say that the mobile cardiovascular telemetry services were medically 
necessary and are supported in the documentation. The Plan denied your request. The Plan says that the 
submitted medical records do not include credentials of the technician for the billed service so the validity and 
accuracy of code 93229 cannot be verified. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan requested generic records but did not specifically request for evidence 
of the technician's credentials. If the Plan intended to deny payment based on the lack of credentials held by the 
technician, they would be required to request proof of the technician's credentials specifically. They would also 
be required to allow a reasonable amount of time for those records to be received. The presence of absence of 
an acronym on a technician's signature line does not necessarily support that they are or are not credentialed to 
provide the service. Based on the records submitted, it does appear that the billed services were performed. 
Therefore, we decided that the Plan has to pay for mobile cardiovascular telemetry services coded as 93229 for 
date of service February 2, 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 procedure codes 87491, 87500, 87640 and 87798 billed for 
date of service July 6, 2022. 
 
You asked the Plan to pay for procedure codes 87491, 87500, 87640 and 87798. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says these 
codes are not supported for reporting. 
 
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 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 procedure codes 87491, 87500, 87640 and 87798. Our 
reviewer says that the codes in question are not supported by the medical record. Our reviewer found the record 
does not show that these tests were ordered or completed, and there is no evidence to clarify the "not otherwise 
specified" code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87491, 87500, 87640 and 87798 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87491, 87500, 87640 and 87798 billed for 
date of service July 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (G0452) provided on March 27, 2023. 
 
You asked the Plan to pay for the pathology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed 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. 
 
We find that CPT code G0452 is not supported in the medical record. Specifically, this code is included in code 
81455. The provided records do not show that this is a separate and distinct procedure. Based on this 
information, we decided that Medicare rules for coverage of the pathology services have not been met. 
Therefore, we decided that the Plan does not have to pay for pathology services (G0452) provided on March 
27, 2023.