Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97116 and 97530 for date of service June 1, 
2023. 
 
You asked the Plan to pay for procedure codes 97116 and 97530. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the codes at issue 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 97116 is therapeutic procedure, 1 or more areas, each 15 
minutes; gait training (includes stair climbing). The CPT Code Manual definition of code 97530 is therapeutic 
activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), 
each 15 minutes. 
 
We find that CPT codes 97116 and 97530 are not supported in the medical record. Specifically, the code 
definition is time-based, and the records submitted for review do not document the total time spent providing 
the services described by this code. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 97116 and 97530 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 97116 and 97530 for date of service June 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2.  
You asked the Plan to pre-approve a Freestyle Libre 2. You say that the criteria for a CGM have been met. The 
Plan denied your request. The Plan says this CGM has been correctly denied. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 2. Our reviewer says 
that the medical criteria for a Freestyle Libre 2 have not been applied. Our physician reviewer found though the 
enrollee has been using medication that can cause low blood sugar; the enrollee does not meet criteria for 
continuous glucose monitor (CGM) device. 
 
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 Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 2.
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. You say that lower levels of care in your area are not 
adequate for the enrollee's condition and an LTACH admission will give the enrollee the best chance possible 
for the best/full recovery. The Plan denied your request. The Plan says admission to an LTACH 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on August 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell 
and your wife called the fire department and the ambulance showed up. You also say that you are now being 
charged for the service. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
 
 The ambulance company did not provide transport services on October 17, 2022 to November 17, 2022. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment with no transport provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 14, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service April 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 2, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E1007, E2377, E2311, E1028, E2313, 
E1012, E2613, E2342, E0978, E0955, E2361, E0973, K0040, E0956, and E1028). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria for a 
Group 3 powered wheelchair. 
 
The Plan follows Medicare rules. The rules say that for equipment to be covered, it must be appropriate and 
needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Medicare rules 
say that a Group 3 power wheelchair (PWC) with multiple power options (such as code K0861) is covered if 
the criteria listed in the Medicare rules section of this letter are met. Medicare rules also say that if the PWC 
base is not covered, then related accessories will be denied. 
 
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 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee lives in a skilled facility, and has an impaired right upper 
extremity following a stroke. The enrollee requires assistance for most activities of daily living. Our reviewer 
found that the enrollee can toilet and feed themself independently. The enrollee is able to use a manual 
wheelchair but requests a power wheelchair for more mobility in the facility. Our physician reviewer also 
found that the power wheelchair will not improve the enrollee's ability to perform self-care activities. 
 
 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 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E1007, E2377, 
E2311, E1028, E2313, E1012, E2613, E2342, E0978, E0955, E2361, E0973, K0040, E0956, and E1028).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leuprolide, Diphenhydramine, Famotidine, Cabazitaxel 
and Enzalutamide. 
 
You asked the Plan to pre-approve Leuprolide, Diphenhydramine, Famotidine, Cabazitaxel and Enzalutamide. 
You say that the medications are medically necessary. The Plan denied your request. The Plan says the 
treatment is not helping you condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 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 Leuprolide, Diphenhydramine, 
Famotidine, Cabazitaxel and Enzalutamide. Our reviewer says that the requested Leuprolide, 
Diphenhydramine, Famotidine, Cabazitaxel and Enzalutamide are not medically necessary. Our physician 
reviewer found Cabazitaxel is not FDA approved for your condition. The requested drugs are not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The 
request for Leuprolide, Diphenhydramine, Famotidine, Cabazitaxel and Enzalutamide cannot be approved 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 Leuprolide, Diphenhydramine, Famotidine, Cabazitaxel and Enzalutamide have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Leuprolide, Diphenhydramine, 
Famotidine, Cabazitaxel and Enzalutamide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service February 2, 2023, 
to February 5, 2023. 
 
You asked the Plan to pay for procedure code 99233. 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 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 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 procedure code 99233. Our reviewer says 
that the documentation does not support the code billed. Our reviewer found the enrollee was treated for 
infected leg wounds and bacteremia. The documentation showed the enrollee was without symptoms, clear 
lungs, without distress with a plan to continue antibiotics but no further debridement. Although the notes 
include appropriate histories and physicals, the documentation for each of the dates fail to show a high level of 
medical decision making as the enrollee was stable without plans for a change in treatment, and without 
positive cultures. Therefore, code 99233 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 for date of service February 2, 2023, to February 5, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on June 1, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says Licensed Professional Counselors (LPCs) are not eligible to bill Medicare 
for mental health services. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy provided on June 1, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography and sleep testing (codes 95810 and 
95811). 
 
You asked the Plan to pre-approve a polysomnography and sleep testing. The Plan denied your request. The 
Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for a diagnosis of OSA to be made, the criteria listed 
in the Medicare rules section of this letter must be 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 a polysomnography and sleep testing. 
Our reviewer says that based on the medical records provided there is no documentation that the 
polysomnography and sleep testing (codes 95810 and 95811) at issue in this case meets all Medicare criteria 
for medically reasonable and necessary for the patient. Our physician reviewer found the provided records in 
this case do not document an Epworth Sleepiness Scale and a physical examination that documents the patient's 
neck circumference and an upper airway system evaluation as required by the LCD for Polysomnography and 
Sleep Testing (L33405). 
 
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 polysomnography and sleep testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a polysomnography and sleep testing (codes 95810 and 95811).
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. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee is receiving the care they need 
in the hospital where they are now and there is no need to transfer to the LTACH at this time.  
 
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 that there are no services the enrollee requires in the LTACH that cannot be provided 
in their current setting and there is no therapeutic benefit to their transfer. 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show that it is medically safe for you 
to go to an LTACH, the enrollee can continue to receive appropriate management safely at the current level of 
care. 
 
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 receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires daily physician 
assessment as well as additional specialty physician consults of pulmonology. The Plan denied your request. 
The Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to 
an LTACH. 
 
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 receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 17, 2023, to June 
15, 2023. 
 
You asked the Plan to pay for home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan follows Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. The claim was billed 
with an invalid type of bill. We find the Medicare rule for payment of this May 17, 2023, to June 15, 2023, 
claim has not been met. Therefore, we decided that the Plan does not have to pay for home health services 
provided from May 17, 2023, to June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service June 11, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the service was not separate and distinct. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 83789 billed for date of service June 11, 2023.