Persius/hicric huggingface dataset:
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 you are requesting an expedited appeal and have 
provided a clinical summary and clinical documentation to support this request. The Plan denied your request. 
The Plan says an IRF admission has not been shown to be medically necessary at this time. 
 
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 significantly complies with the various documentation requirements for IRF 
admission including documenting the enrollee's ability to tolerate IRF-level care, as best summarized by the 
physical and occupational therapy evaluations from October 15, 2023. The enrollee's condition is in fact 
complex and fragile, and there is every reason to expect that they will participate in and benefit from services 
to include at minimum physical and occupational therapy, physician oversight of polypharmacy and case 
manager coordination of any additional services that might be needed to make a sustainable return home, as 
well as avoid further preventable readmissions to the acute hospital. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for dates of service March 22, 
2023 to March 30, 2023. 
 
You asked the Plan to pay for procedure code 97010. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for dates of service March 22, 2023 to March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on May 17, 2023, 
and May 18, 2023. 
 
You asked the Plan to pay for subsequent hospital care (99233). You say that the services provided were 
necessary for the treatment of their condition and code 99233 accurately reflects the treatment. The Plan denied 
your request. The Plan says the medical records submitted do not support high level of medical decision 
making or total time required for the code 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 99233 is subsequent 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, 50 minutes must be met or exceeded. 
 
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 subsequent hospital care (99233). Our reviewer says that 
procedure code 99233 is not supported. Our reviewer found there was no high level of medical decision 
making and documentation of at least 50 minutes of total of time spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital care (99233) have not been met. Therefore, we decided that 
the Plan does not have to pay for subsequent hospital care (99233) provided on May 17, 2023, and May 18, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on October 13, 2022. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on October 13, 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 live alone and are currently unable to care for 
yourself. You feel the requested IRF services will assist in your recovery and  will be beneficial in regaining 
your strength. The Plan denied your request. The Plan says your condition 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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require the 
oversight of a rehabilitation physician. You have had no significant post-operative complications and no acute 
changes in your medical conditions other than undergoing the planned surgery. Your medical and rehabilitation 
needs do not require the intensive interdisciplinary approach provided on acute inpatient rehabilitation. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven 
consecutive days. You have had a decline from your baseline level of function and may benefit from 
occupational therapy and physical therapy as well as supervision and assistance, but you do not require the 
intensity of therapies provided on acute inpatient rehabilitation. Therefore, the IRF admission is not medically 
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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the hearing aids provided on March 10, 2022. 
 
You asked the Plan to pay more for the hearing aids. You say that you are requesting reconsideration of the 
overpayment audit findings for the services performed on March 10, 2022. The Plan denied your request. The 
Plan says this is an adjustment on a previously processed claim. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only reimburse up to $1,700 per ear every 36 months towards the cost of hearing aids.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay more 
for the hearing aids provided on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel (87798, 87631) provided on January 2, 
2023. 
 
You asked the Plan to pay for the respiratory panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with greater than 5 respiratory pathogens 
performed in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case the records show that this panel tested for more than 5 
respiratory pathogens. Based on this information, we decided that Medicare rules for coverage of the 
respiratory panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory panel (87798, 87631) provided on January 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left-sided lumbar transforaminal epidural steroid 
injections. 
 
You asked the Plan to pre-approve left-sided lumbar transforaminal epidural steroid injections. You say that 
repeat left-sided lumbar transforaminal epidural steroid injections are medically necessary. The Plan denied 
your request. The Plan says the requested repeat left-sided lumbar transforaminal epidural steroid injections are 
not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that lumbar transforaminal epidural steroid injections are 
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 left-sided lumbar transforaminal 
epidural steroid injections. Our reviewer says that the requested left-sided lumbar transforaminal epidural 
steroid injections are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee underwent left TFESI L34 and L45 in January 2023, which provided 100% relief for 23 
weeks. The Medicare coverage criteria for success is 50% pain relief for 3 months, which has not been met. 
Therefore, the request is deemed not medically reasonable and 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 left-sided lumbar transforaminal epidural steroid injections have not been met. 
Therefore, we decided that the Plan does not have to pre-approve left-sided lumbar transforaminal epidural 
steroid injections.
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 need rehab to regain daily function and manage 
your diabetes, hypertension and renal function. The Plan denied your request. The Plan says you do not have 
complex rehabilitation, medical, and nursing needs.  
 
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 are medically stable and near your prior level of function. You do not require 
treatment by multiple therapies, including physical or occupational therapy, and an intensive rehabilitation 
therapy program. There is not a reasonable expectation that you 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555, 
L8680). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of Sprint PNS system in the setting of 
myofascial pain syndrome and occipital neuralgia have not been demonstrated in the peer-reviewed literature. 
 
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 Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Sprint PNS device is experimental for occipital neuralgia. 
 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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555, L8680).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 8, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on March 8, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergent ambulance transportation services provided on June 
1, 2023. 
 
You asked the Plan to pay for the non-emergent ambulance transportation services. You say that the services 
were medically necessary. The Plan denied your request. The Plan says that the transport was not medically 
necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent ambulance transportation 
services. Our reviewer says that the non-emergent transport service services were medically necessary. Our 
physician reviewer found the enrollee did require the additional support during transport due to safety 
concerns. The enrollee has generalized weakness and confusion, and although unable to sit in bed they were 
still able to move all extremities and therefore they were at an increased fall risk. 
 
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 non-emergent ambulance transportation services have been met. Therefore, 
we decided that the Plan has to pay for the non-emergent ambulance transportation services provided on June 
1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy infusion services provided on June 13, 2023. 
 
You asked the Plan to pay for chemotherapy infusion services. You say that the services were medically 
necessary. 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 chemotherapy infusion 
services provided on June 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion. 
 
You asked the Plan to pre-approve SI joint fusion. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SI joint fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no SI joint instability, fracture, or lesion. SI joint fusion for degenerative back pain is 
experimental. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on April 3, 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 CPT 99284 has been downcoded to CPT 99283. 
 
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 a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 medical decision making of 
moderate complexity requires 2 out of 3 of multiple diagnoses or management options, a moderate amount and 
complexity of data reviewed and moderate risk of complication. The provided records in this case do not 
document 2 out of 3 of multiple diagnoses or management options, a moderate amount and complexity of data 
reviewed and moderate risk of complication. 
 
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 emergency room services (procedure code 99284) rendered on April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2023, billed with 
codes 87481, 87500, 87640, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the testing billed. The Plan denied your request. The Plan says panel testing 
should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that a wound panel was provided. We looked at the file and Medicare rules. This NGS panel 
was not billed with a single code as required. Based on this information, we decided that Medicare rules for 
coverage of the testing billed have not been met. Therefore, we decided that the Plan does not have to pay for 
the genetic testing provided on April 27, 2023, billed with codes 87481, 87500, 87640, 87641, 87651, 87653, 
and 87798.