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

 
We decided that the Plan does not have to pay for the services (J2250, 99152, 99153) provided on January 11, 
2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. 
 
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 use of codes J2250, 
99152, and 99153, is not supported by the records provided. Our reviewer found that there is no documentation 
stating that midazolam hydrochloride was administered. As such, code J2250 is not supported. The record does 
not state the amount of time the provider spent at the patient's bedside providing moderate sedation, or that a trained independent observer was present for the duration. Therefore, codes 99152 and 99153 are not 
supported. 
 
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 the services (J2250, 99152, 99153) provided on January 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage for additional SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular electrical stimulator (NMES) provided on 
April 20, 2023. 
 
You asked the Plan to pay for NMES. You say that this denial is inaccurate. The Plan denied your request. The 
Plan says this use of NMES does not meet Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules state that neuromuscular electrical stimulation (NMES) may 
be covered under certain conditions. 
 
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 NMES. Our reviewer says that this NMES 
does not meet criteria for payment. Our physician reviewer found provided records do not document muscle 
disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, 
and other non-neurological reasons for disuse atrophy. In addition, the records do not document a spinal cord 
injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NMES have not been met. Therefore, we decided that the Plan does not have to 
pay for a neuromuscular electrical stimulator (NMES) provided on April 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement motor and/or gearbox and push bar. 
 
You asked the Plan to pre-approve the accessories. You say that you were told that the motors are running in a 
way that suggests they are at least 2.5 years old. You say that you need this to be replaced. You also say that 
this motorized wheelchair is medically necessary for you. The Plan denied your request. The Plan says the 
motors are in working condition according to the technician who looked at the motors. The Plan also says that 
the requested replacement parts are considered convenience items and do not affect the function of the power 
wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that carriers may determine the reasonable useful 
lifetime of equipment, but in no case can it be less than 5 years. Replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a replacement motor and/or gearbox and push bar.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of the CardioMEMs 
device has 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 CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer 
found that the requested CardioMEMS device 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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS device (33289).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 7, 2023, billed with 
codes 87481, 87801, 87651, 87150, 87798, and 87641. 
 
You asked the Plan to pay for the genetic testing billed. You say that the documentation shows the services 
were rendered. 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 urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel testing was not billed with a single code as required. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic testing provided on May 7, 2023, billed with codes 87481, 87801, 87651, 
87150, 87798, and 87641.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 80307, 83789, and G0480 for date of service April 19, 
2023. 
 
You asked the Plan to pay for procedure codes 80307, 83789, and G0480. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says that the billed services were not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan states that the billed services were not 
supported. No explanation on why these codes are not supported was included in the documentation. No other 
denial rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan 
has to pay for procedure codes 80307, 83789, and G0480 for date of service April 19, 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: 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 exceeds the criteria for an 
LTACH appropriate admission. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in 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 appears to be currently unstable for transfer and requires additional 
acute care services that can safely be provided at the current facility. There are no services at the LTACH that 
the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH 
would not be clinically advantageous at this time and completion of treatment at the current facility is 
recommended.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the power scooter and set up. 
 
You asked the Plan to reimburse you for the power scooter. You say that you purchased a mobility scooter for 
use in and out of your house. You say that this scooter is designed for quick turns. You also say that you have 
very limited walking ability. The Plan denied your request. The Plan says the records do not show that your 
home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power 
vehicle that is provided.  
 
The Plan must follow Medicare rules. Medicare rules say that prior to or at the time of delivery of a power 
operated vehicle (POV) or power wheelchair (PWC), the supplier or practitioner must perform an on-site 
evaluation of the beneficiarys home to verify that the beneficiary can adequately maneuver the device that is 
provided. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power scooter have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the power scooter and set up.
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 an expedited appeal for the denial 
of an IRF admission. 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. The enrollee's 
medical status does not require intensive rehabilitation physician or nursing oversight in an IRF. The enrollee's 
functional level does not require treatment by multiple therapies including physical or occupational therapy in 
an intensive rehabilitation program in an IRF. While the enrollee may benefit from additional therapy, the 
documentation does not support that they require or can fully tolerate this therapy on an IRF level.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee's medical needs are being met in the current setting. 
 
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 record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary, and it is not 
safe for you to return home. The Plan denied your request. The Plan says you do 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 you do not require the intensity of services provided at an IRF. You are not shown to 
require fifteen 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95886, 95955, 95937, 95908 and 95927 
billed for date of service August 11, 2021. 
 
You asked the Plan to pay for procedure codes 95886, 95955, 95937, 95908 and 95927. You say that these 
services were necessary and were reported appropriately. The Plan denied your request. The Plan says these 
services are not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 95886, 95955, 95937, 95908 and 95927. 
Our reviewer says that these codes are not supported in the records provided. Our reviewer found that code 
95886 is not supported, as nerve conduction studies cannot be verified in the records provided. Procedure code 95955 is not supported, as the procedure report describes neuromonitoring for, hardware removal, posterior 
L2-S1 was performed. In this case, there is a more specific code to report the service provided. Code 95937 is 
not supported, as this code was used to describe train of four testing. Train of four testing does not have an 
assigned CPT code as it is inclusive to the primary neuromonitoring procedure and should not be separately 
reported. Code 95908 is not supported, as the procedure report describes pedicle screw stimulation, which 
would not be reported with nerve conduction as amplitude and latency/velocity are measured. Lastly, code 
95927 is also not supported, as this procedure was not found in the medical record. The codes at issue are not 
supported as billed. 
 
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 95886, 95955, 95937, 95908 and 95927 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95886, 95955, 95937, 95908 and 
95927 billed for date of service August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83520, 87798) provided on December 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT codes 83520, & 87798 are not supported in the medical record. Specifically, these codes 
represent services Not Otherwise Specified. The lab request does not include a detailed description of what the 
Not Otherwise Specified codes represent. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (83520, 87798) provided on December 18, 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 fell and need inpatient rehabilitation to return 
home safely. The Plan denied your request. The Plan says your records do not show that you need an intensive 
team to manage your care, or that you can safely tolerate three hours of intensive therapies a day. The Plan says 
that the services needed may be provided safely in a lower level of 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 your 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no magnetic resonance imaging 
(MRI) showing modic changes without facet degenerative joint disease or stenosis. The cause of the enrollee's 
pain is not clear. The Intracept procedure is therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.