Persius/hicric huggingface dataset:
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 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. 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 at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. 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 health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prednisone tab 20 mg. 
 
You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prednisone tab 20 mg.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) skilled nursing home visits (G0299). 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration. The 
denial can jeopardize the enrollee's ability to regain maximum function.  The Plan denied your request. The 
Plan says the records do not show that the enrollee is under the care of a physician or other allowed practitioner 
who has developed and certified a plan of care. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the records do not show that the enrollee is 
under a plan of care with his physician. Medicare says that a doctor must certify the need for home health care 
services. Therefore, we decided that the Plan does not have to pre-approve two (2) skilled nursing home visits 
(G0299).
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 wound care doctors recommended inpatient rehab 
since your stomach wound is not healing. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
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 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that 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 an out-of-network referral for plastic surgery. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the out-of-network exception criteria has not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for plastic surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37228, 37232, 75630, and 75710 rendered 
on October 11, 2022. 
 
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 the 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 the denied codes is: 
 
CPT 37228: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty 
 
CPT 37232: 
 
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; 
with transluminal angioplasty (List separately in addition to code for primary procedure) 
 
CPT 75630: 
 
Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological 
supervision and interpretation 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
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 the medical records do not 
support that CPT 75630 and CPT 75710 were done separately and distinctly from procedure code 37225. The 
medical records do not support the use of CPT 37228, as there is a more appropriate code to use when there is a 
selective cauterization performed on the right peronal artery. The medical records also do not support the add-
on code CPT 37232, as there is a more appropriate code to use with the add on of the selective cauterization of 
an artery with angioplasty. 
 
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 procedure codes 37228, 37232, 75630, and 75710 rendered on October 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray, 3 views (73562) provided on February 21, 
2023. 
 
You asked the Plan to pay for the x-ray. 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 must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the x-ray have not been met. Review of the file shows that 
procedure code(s) 73562 has a status indicator of Q1, according to Addendum B - Outpatient Prospective 
Payment System (OPPS) Payment by Healthcare Common Procedure Coding System (HCPCS) Code for CY 
2023. CPT code 99283 was billed on the same claim, with the same date of service, with a revenue code of 
450. According to the Integrated Outpatient Code Editor (I/OCE) Quarterly Release Files, this gives Current Procedural Terminology (CPT) code 99283 a status indicator of V (clinic or emergency department visit). 
Therefore, procedure code 73562, which has a status indicator of Q1, is not separately payable. Therefore, we 
decided that the Plan does not have to pay for the knee x-ray, 3 views (73562) provided on February 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an anterior cervical discectomy and fusion. 
 
You asked the Plan to pre-approve an anterior cervical discectomy and fusion. You say that you want to appeal 
the denial. The Plan denied your request. The Plan says this procedure 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 an anterior cervical discectomy and 
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 detailed documentation regarding a trial and 
failure of recent less invasive conservative care measures. Additionally, the recent exams do not document 
subjective complaints of pain or functional deficits that affect daily activities or significant objective deficits. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. 
 
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 anterior cervical discectomy and fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an anterior cervical discectomy and fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; 
therapeutic exercises to develop strength and endurance, range of motion and flexibility (97110) and 
therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional 
performance), each 15 minutes (97530). 
 
You asked the Plan to pay for the services. You say that the enrollee has been being treated for 
balance/strengthening since June 14, 2022, and all visits have received prior authorization. The Plan denied 
your request. The Plan says the diagnosis codes associated to it, R26.9 (Unspecified abnormalities of gait and 
mobility) and R27.0 (Ataxia, unspecified), should not be reported together.  
 
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 services. Our physician reviewer found 
the medical records do not support that diagnoses codes R27.0 and R26.9 should be reported together. Coding 
guidelines says that there is an Excludes1 note with R26.9 excluding R27.0. Medical records do support 
diagnosis code R26.9, but do not support diagnosis R27.0. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop 
strength and endurance, range of motion and flexibility (97110) and therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes (97530).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Epifix. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the wound has not healed using first-line standard approaches. As such, the wound requires an 
alternative second-line approach such as Epifix. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve Epifix.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0428HN and A0425HN) provided 
on December 30, 2022. 
 
You asked the Plan to pay for the ambulance services . You say that you are requesting this claim be 
reprocessed. The Plan denied your request. The Plan says the information submitted does not support this many 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 ambulance services. Our reviewer found the review 
indicates that ambulance services used for the transportation of a hospital inpatient to another facility for 
diagnostic tests or special treatment for example is considered part of the inpatient admission, and not separately payable. Once a member is admitted to an Inpatient Hospital or Critical Access Hospital (CAH), it 
may be necessary to transport the member to another hospital or other site temporarily for specialized care 
while the member maintains inpatient status with the original provider. This movement of the patient is 
considered "patient transportation" and is covered as an inpatient hospital or CAH service. Transportation 
services (A0021-A0999, S0207-S0215, S9960-S9961) are not separately payable from the payment to the 
inpatient institution. The review has determined that the reviewed documentation did not support procedure 
code the ambulance services (A0428HN and A0425HN) provided on December 30, 2022. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services (A0428HN and A0425HN) provided on December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit for the evaluation and 
management of a patient (99285) provided on February 11, 2023. 
 
You asked the Plan to pay for the service. You say that you are requesting reconsideration for services advising 
the coding department has reviewed the services and determined that the claim is coded correctly. The Plan 
denied your request. The Plan says R41.82 (Altered mental status, unspecified) and R40.20 (Unspecified 
coma), should not be reported together which is 
based on the Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. 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 service. Our 
reviewer found the provider reported diagnosis codes: Diagnosis code R41.82 (Altered mental status, 
unspecified) and R40.20 (Unspecified coma) for service provided. The documentation submitted was reviewed 
and does not meet criteria. ICD 10 guidelines for diagnosis R41.82 has an Excludes1 which includes altered 
level of consciousness (R40. 0). In this case, the claim denied correctly, as the diagnosis codes were incorrectly 
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 the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department visit for the evaluation and management of a patient (99285) 
provided on February 11, 2023.
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 will need another 3-4 weeks 
to continue weaning down her oxygen needs and to transition from her acute illness. The Plan denied your 
request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 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 health plan. The health plan has approved ongoing 
care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
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 pre-approve hyperbaric oxygen therapy (G0277). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the requested HBO therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that diabetic wounds of the lower extremities must 
meet the following three criteria, have type I or type II diabetes and has a lower extremity wound that is due to 
diabetes, has a wound classified as Wagner grade III or higher; and has failed an adequate course of standard 
wound therapy. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hyperbaric oxygen therapy have not been met. Specifically, the records show that the enrollee does 
not meet criteria for approval because the enrollee does not have a wound classified as Wagner grade III or 
higher. The records show the enrollee has a wound classified as Wagner II. Therefore, we decided that the Plan 
does not have to pre-approve hyperbaric oxygen therapy (G0277).