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

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter revascularization (PTR). 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the doctor needs to send in additional documentation. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that angiography shows that the disease is infra-popliteal with segments of chronic total 
occlusion bilaterally and both lower extremities noted to be well perfused on physical examination. As such, 
guidelines for peripheral revascularization are not met. In summary, there is insufficient documentation to 
support the medical necessity for peripheral revascularization in this patients clinical management.  
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transcatheter revascularization (PTR).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided on September 24, 2022, billed with code 52204-XU.

You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does not support the billed code.

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 52204 is a column II code to column I code 52332; however, 52204 was billed with a modifier.

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 imaging services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found the procedure report describes, bilateral stent placement, and in this case cystourethroscopy, with biopsy would be included in the stent placement. The documentation does not support billing biopsy as a separate procedure from stent placement.

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 imaging services provided have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided on September 24, 2022, billed with code 52204-XU.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested item is not a covered benefit with the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We looked at the file and Medicare rules. The requested item is not a covered benefit with the plan because 
they are not primarily medical in nature. Based on this information, we decided that Medicare rules for 
coverage of a wheelchair accessory have not been met. Therefore, we decided that the Plan does not have to 
pre-approve power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364) and a consultation (D9310) provided 
on August 25, 2022. 
  
You asked the Plan to pay for the dental service. You say that the directory showed the provider being an in-
network provider and the dental services should be covered. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because the cone beam and consultation are not covered by the 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam (D0364) and a consultation (D9310) provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulation (PNS) device. 
 You asked the Plan to pre-approve a Sprint PNS device. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this 
peripheral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Sprint peripheral nerve stimulation (PNS) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
The elements of the coverage criteria are not satisfied. The requested service cannot be 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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. The Plan denied your request. The Plan says the inpatient 
rehabilitation request is not supported on the records received; the enrollee needs help with self-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 the enrollee's 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services. The Plan denied 
your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure code 99223 and 99233) rendered 
from July 17, 2022, to July 18, 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 Current Procedural Terminology (CPT) code 99223 and 99233 remain 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 the denied codes is: 
 
CPT 99223: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
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 in terms of CPT 99223, the 
medical records submitted did not support medical decision making of high complexity. In terms of CPT 
99233, the medical records submitted did not support a detailed interval history and medical decision making 
of high complexity. 
 
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 hospital care (procedure code 99223 and 99233) rendered from July 17, 2022, to July 18, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for arthrotomy, with synovectomy, knee; anterior AND posterior including 
popliteal area rendered on September 1, 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 that CPT 27335 is considered inclusive to CPT 27447. 
 
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 27335 is "Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area." 
 
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 supported by the medical records. Our reviewer found that the records support CPT 27335 as a 
separate and distinct procedure from CPT 27447. The procedure details cite a full, three-compartment 
synovectomy that was performed including the suprapatellar pouch, the peripatellar region, both gutters, and 
the posterior compartment. This procedure was performed after the meniscal tissue and posterior osteophytes 
were removed. The trials were placed after this. This supports the synovectomy as being a separate procedure. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area rendered on September 
1, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor 
(33285) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve insertion of a subcutaneous cardiac rhythm monitor to be provided by an 
OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are 
in-network providers that are able to provide these services. Therefore, coverage criteria have 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 
insertion of a subcutaneous cardiac rhythm monitor (33285) to be provided by an out-of-network (OON) 
provider.
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. The Plan denied your request. The Plan says the 
enrollee does not meet all the requirements based on Medicare guidelines and the information we have, 
services needed may be provided safely in a lower 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 August 18, 2022, to 
September 16, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 19, 2022. The NOA was not received by the Plan until December 2, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 18, 2022, to September 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A0425 billed for date of service October 31, 2022. 
 
You asked the Plan to pay for code A0425. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 298 units of 
this code on the same claim line, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of code A0425 have not been met. Therefore, we decided that the Plan does not have to pay 
for code A0425 billed for date of service October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a synergy seating frame X unit (K0108). 
 
You asked the Plan to pre-approve a synergy seating frame X unit. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says a request for a nonstandard sized seat 
is unbundled and cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules show that for all adult manual wheelchairs, payment 
for seat widths and/or seat depths of 15-19 inches is included in the payment for the base code. These seat 
dimensions should not be billed separately. The records show that the enrollee has a hip width of 17 and this 
accessory should not be billed separately. Based on this information, we decided that Medicare rules for 
coverage of a synergy seating frame X unit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a synergy seating frame X unit (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics provided on December 8, 2022. 
 
You asked the Plan to pay for the foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for the foot 
orthotics provided on December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.

brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use of benefits.

We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand for a continuous glucose monitor (CGM). Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).