Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is weak and needs therapy services 
before returning home. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 20, 2023, billed with 
procedure codes 00670-AA and 64488-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says there is insufficient information to support the 
billed service. 
 
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 practitioner services provided have 
been met. Specifically, the anesthesia report provided does not include the name of the enrollee to support the 
service billed (00670). Since there is a National Correct Coding Initiative (NCCI) edit between codes 64488-59 
and 00670, code 64488 cannot be verified. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on March 20, 2023, billed with procedure codes 00670-AA and 64488-59.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99284 billed for date of service November 7, 2022. 
 
You asked the Plan to pay for code 99284. You say that the provider was not contracted with the Plan on the 
date of service. The Plan denied your request. The Plan says billed code 99284 is not supported by the medical 
record and was downcoded to 99282. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate 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 99284. Our reviewer says that code 99284 is not supported by the medical record. Our reviewer found the enrollee is a 77-year-old female who presented to the 
emergency department with report of altered mental status following baclofen use. The documentation 
describes an expanded focus history, detailed exam, but stable vitals and only a low complexity level of 
decision making. Therefore, code 99284 is not supported and the downfolding to 99282 appears appropriate 
based on the provided documentation.  
 
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 99284 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99284 billed for date of service November 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar laminectomy. 
 
You asked the Plan to pre-approve the surgery. You say that surgical intervention is appropriate given the 
severity of the spinal stenosis. The Plan denied your request. The Plan says the lumbar laminectomy 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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. There are limited large-scale, long-term references showing 
the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested lumbar laminectomy at L2-3, L3-4, and L4-5 is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar laminectomy.
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. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 this 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 pre-approve a replacement prosthetic foot (L5987). 
 
You asked the Plan to pre-approve a replacement prosthetic foot. You say that the item is necessary. The Plan 
denied your request. The Plan says the enrollee's current prosthetic foot is still under warranty. Based on the 
documentation provided, coverage criteria have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a replacement prosthetic foot have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a replacement prosthetic foot (L5987).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99152 billed for date of service March 23, 2023. 
 
You asked the Plan to pay for code 99152. You say that you have supplied medical records to support payment 
of this code. The Plan denied your request. The Plan says code 99152 is not supported by the medical records. 
The records don't indicate the intra-service time for moderate sedation 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. 
 
In this case, the CPT Code Manual definition of code 99152 is Moderate Sedation provided by the same 
physician or other qualified health care professional performing the diagnostic or therapeutic service that the 
sedation supports for patients 5 years of age or older for the first 15 minutes of intraservice time. 
 
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 99152. Our reviewer says that code 99152 is not supported by the medical record. Our reviewer found the medical records submitted do not include 
documentation of intraservice time, therefore this service 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 code 99152 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99152 billed for date of service March 23, 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 are requesting reconsideration for the denial of 
an IRF admission with documentation provided to support medical necessity. The Plan denied your request. 
The Plan says the enrollee's needs can be met at a lower level of care such as a skilled nursing facility or home 
health 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they meet criteria for admission to an acute 
inpatient rehabilitation facility. 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: 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 admission to an IRF is necessary for you to receive 
an appropriate level of physical therapy rehabilitation. 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 you do not require the intensity of services provided at an IRF.  You are not shown to 
require 15 hours per week of rehabilitative services and regular physician evaluation.  Your care needs can be 
met 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: 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 an inpatient rehabilitation facility would help regain 
maximum function. The Plan denied your request. The Plan says admission into an inpatient rehabilitation 
facility 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 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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that this 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 pre-approve shoe lifts (L3334). 
 
You asked the Plan to pre-approve shoe lifts. You say that the item should be covered. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve shoe lifts (L3334).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery (22633, 22840, 22853, 20930, 
20936). 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 spinal fusion surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested fusion at L2-3 is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery (22633, 22840, 22853, 20930, 20936).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0326U for date of service February 15, 2023. 
 
You asked the Plan to pay for procedure code 0326U. 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 0326U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, 
gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0326U is not supported in the medical record. Specifically, the medical records 
submitted include a signed order and corresponding results; however, the records did not include sufficient 
details to support the service as billed. In addition, the billed date of service must be the specimen collection date. Based on this information, we decided that Medicare rules for coverage of procedure code 0326U have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0326U for date of 
service February 15, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan concurrently with a CT scan of the skull 
base to mid-thigh. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says repeat PET scans are not supported for treatment planning. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 the PET/CT scan. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that there is no rationale given by the 
requesting physician regarding the need for another PET scan. The second CT scan showed no change since the 
initial scan was performed. The medical necessity of the requested repeat PET/CT has not been established in 
the submitted records. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a PET scan concurrently with a CT scan of the skull base to mid-thigh.