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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires aggressive therapy to regain 
functional mobility to return to their previous level of independence. The Plan denied your request. The Plan 
says an IRF admission 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 enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861) and related accessories and features.  
You asked the Plan to pre-approve a Group 3 power wheelchair and related accessories. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested items are 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 a Group 3 power wheelchair and related 
accessories. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that the enrollee has cerebral palsy. The enrollee is able to transfer 
modified independently and has capacity to stand with stand-by assist. The enrollee has intact skin and does not 
have high risk for skin breakdown. The enrollee does not use a catheter intermittently, have spasticity or 
require an alternative means of managing power drive. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 power wheelchair and related accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (K0861) and related accessories and features.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366 and 96521 billed for date of 
service April 4, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366 and 96521. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided 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 96365 is: Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is: Intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour. The 
definition of code 96521 is: Refilling and maintenance of portable pump.  
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 96365, 96366 and 96521. Our reviewer says 
that procedure codes 96365, 96366 and 96521 do not meet criteria for payment. Our reviewer found that with 
regard to procedure codes 96365 and 96366, the medical record describes infusion of insulin (Novolin R) 
treatment provided for an outpatient. In this case, there is a more specific procedure code that should be 
reported for the services documented. With regard to code 96521, the procedure report includes a physician 
order for refilling and maintenance of a portable pump; however, documentation does not support the 
procedure was performed and therefore 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 procedure codes 96365, 96366 and 96521 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 96365, 96366 and 96521 billed for date of 
service April 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services coded as 99223 
performed on December 9, 2022. 
 
You asked the Plan to pay for 99223. You say that code 99223 is accurate and supported in the documentation. 
The Plan denied your request. The Plan says code 99223 is not supported because the documents provided do 
not contain an evaluation and management service provided on December 9, 2022. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded.  
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 99223. Our reviewer says that code 99223 is 
not supported in the documentation. Our reviewer found that medical decision making of high complexity 
requires 2 out of 3 the following: of an extensive number of diagnoses or management options, an extensive 
amount and complexity of data reviewed, and high risk of complication. Provided records in this case do not 
document 2 out of 3 of these criteria. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99223 have not been met. Therefore, we decided that the Plan does not have to 
pay for evaluation and management services coded as 99223 performed on December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Red Elephant heavy duty mobility scooter received on 
August 26, 2022. You asked the Plan to pay for the Red Elephant heavy duty mobility scooter. You say that you disagree with 
how the claim was processed and believes it should be a different outcome. The Plan denied your request. The 
Plan says the item received is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. The documentation states that you are unable to 
ambulate in the community including shopping or running errands. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. In addition, the documentation did not 
include a home assessment to ensure that this device would be suitable for the use in your home. Therefore, we 
decided that the Plan does not have to pay for the Red Elephant heavy duty mobility scooter received on 
August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio external upper limb tremor stimulator 
(K1018). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that a Cala Trio device is a necessity for your 
care. The Plan denied your request. The Plan says a Cala Trio device 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 a Cala Trio device. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is insufficient evidence in the literature that this device is effective for the enrollee's 
tremor. The requested device is not the standard of care for the enrollee's tremor according to current 
guidelines.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio external upper limb tremor stimulator (K1018).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve an electronic connection. 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 an electronic connection. 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 upper extremities to manage 
standard power drives. 
 
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 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and one power seating 
system motor (E2310).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional units of procedure code 88341 billed for date 
of service March 3, 2023. 
 
You asked the Plan to pay for the additional units of procedure code 88341. You say that the attached 
documents should be reviewed, and the claim processed for payment. The Plan denied your request. The Plan 
says records have not been received to support the services billed.  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 procedure code 88341 have been met. 
Specifically, medical records to support the additional units billed were not submitted. Therefore, we decided 
that the Plan does not have to pay for the additional units of procedure code 88341 billed for date of service 
March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan (D0383) 
provided on March 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam computed tomography (CT) scan (D0383) provided on March 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 27, 2023, 
to March 1, 2023.  
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary.  
The Plan denied your request. The Plan says the referral was not approved.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the workup ruled out other more serious conditions causing the enrollee's symptoms. 
The enrollee was started on thyroid hormone supplementation. It was not expected that the enrollee would 
require hospital care that would have likely crossed 2 midnights based on the stability of the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided February 27, 2023, to March 1, 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 feel the enrollee meets Medicare criteria and 
will benefit from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says an 
LTACH admission 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 enrollee is improving and only requires short-term acute care at the current 
facility until they ae more appropriate for transfer to a lower level of care. The enrollee does not require 
services at the LTACH that are not already available at the current facility. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service March 2, 2023. 
 
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 code billed is not supported.  
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is indicated when: 
1. The results of the screen are presumptively positive. 
2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical 
history. 
3. This test may also be used, when the coverage criteria of the policy are met AND there is no 
presumptive test available, locally and/or commercially, as may be the case for certain synthetic or 
semi-synthetic opioids. 
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 payable as billed. Specifically, the medical records show that a definitive 
urinary drug testing panel for multiple drug classes was performed but does not show screening test results 
which are positive or inconsistent with prescription medications, dosing schedules, or history and expected 
results. Definitive testing is only covered when the results of the screen are presumptively positive and when 
the results of the screen are negative, and this negative finding is inconsistent with the enrollees medical 
history. Without the test results showing one of these factors, the services are not covered as billed. 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 March 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (70553) provided on March 16, 2023. 
 
You asked the Plan to pay for imaging services. You say that this claim was submitted with appropriate 
diagnosis codes. The Plan denied your request. The Plan says this claim was submitted with two diagnosis 
codes which have conflicting laterality. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, 
right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both 
the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of imaging services have not been met. Specifically, this claim was submitted with both diagnosis 
codes H90.3 (sensorineural hearing loss, bilateral) and H90.5 (unspecified sensorineural hearing loss). The 
same condition should not be reported as both bilateral and unspecified. The unspecified code should only be 
used when documentation in the record is insufficient to determine the affected side and it is not possible to 
obtain clarification. Therefore, we decided that the Plan does not have to pay for imaging services (70553) 
provided on March 16, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on February 27, 2023. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration for the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient mental health 
provided on February 27, 2023.