Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission are medically 
necessary. The Plan denied your request. The Plan says the notes do not show that the enrollee's care 
specifically requires the involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show 
that the enrollee has complex care needs that require a coordinated team approach; the notes do not show that 
the enrollee must have an intensive therapy program (3 Hours a day, at least 5 days a week) in order to improve 
self-care functioning. 
 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 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. The 
enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 
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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted modality (specify type and time if constant 
attendance) (97039) provided by a chiropractor on August 24, 2023. 
 
You asked the Plan to pay for unlisted modality (specify type and time if constant attendance) (97039). You 
say that the service was provided by a chiropractor, and you do not agree with the denial of payment for the 
service you received. The Plan denied your request. The Plan says the service is not covered under your 
contract under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for unlisted modality (specify type and time if constant attendance) (97039) 
provided by a chiropractor on August 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper-limb tremor nerve stimulator (K1018) and 
supplies (K1019). 
 
You asked the Plan to pre-approve an upper-limb tremor nerve stimulator and supplies. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested items are experimental/investigational. 
 
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 upper-limb tremor nerve stimulator 
and supplies. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that the provided records in this case do not document trial and 
failure of all first-line and second-line therapies for the enrollee's tremor. The provided records do not clarify that the tremor is refractory to all possible pharmacologic treatment. The provided medical records and review 
of the current peer-reviewed medical literature do not document that use of the requested device has been 
shown in controlled studies in a Medicare-approved journal to result in sustained long-term health benefits in 
patients with essential tremor. 
 
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 upper-limb tremor nerve stimulator and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an upper-limb tremor nerve stimulator 
(K1018) and supplies (K1019).
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 medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage.  
 
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. The enrollee 
was admitted for a compression fracture after a fall. There are no complex nursing or rehabilitation needs. The 
enrollee does 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 this 
enrollee 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on June 7, 2023. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you have a history of blood 
clots and you passed out. You regained consciousness and did not feel that transportation was necessary. The 
Plan denied your request. The Plan says non-transport ambulance services are not covered. 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 June 7, 2023. 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 non-transport ambulance services 
provided on June 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nerve decompression surgery (64722). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided medical records and review of the current peer-reviewed medical literature do not 
clarify that occipital nerve decompression surgery has been shown in controlled studies in a Centers for 
Medicare & Medicaid Services (CMS) approved journal to result in sustained long term health benefits in 
Medicare patients with occipital neuralgia.   
The current literature states that surgical decompression is not a routine therapeutic measure and should be 
reserved for use in a tertiary care center with expertise in peripheral nerve neurosurgery. The provided records 
in this case and review of available information regarding the requested neurosurgery practice do not clearly 
document that the procedure would be performed in a tertiary care center with expertise in peripheral nerve 
neurosurgery.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nerve decompression surgery (64722).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 44015 rendered on August 2, 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 procedure code 44015 is not supported by the medical records submitted. 
 
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 44015 is "Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List 
separately in addition to primary procedure)." 
 
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 describe the 
process of insertion of the feeding tube. This supports the use of CPT 44015. 
 
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 
procedure code 44015 rendered on August 2, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313) for an 
approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller. You say that this controller is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when 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 expandable controller. Our reviewer 
says that the expandable controller is not medically necessary. Our physician reviewer found the records show 
that the enrollee is capable of operating the power features using the standard switches. 
 
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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313) for an approved power 
wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 28, 2023, and billed 
with codes 87493 and 87798. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided on July 28, 2023, and billed with codes 87493 and 
87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prostatic urethral lift (PUL) using the UroLift System. 
 
You asked the Plan to pre-approve a prostatic urethral lift (PUL) using the UroLift System. You say that the 
requested PUL using the UroLift System is medically necessary. The Plan denied your request. The Plan says 
the requested PUL using the UroLift System 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 a prostatic urethral lift (PUL) using the 
UroLift System. Our reviewer says that the requested PUL using the UroLift System is not medically 
necessary. Our physician reviewer found the records do not show an American Urological Association (AUA) 
or International Prostate Symptom Score (IPSS) or maximum flow rate to confirm that he has bladder outlet 
obstruction.  
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 prostatic urethral lift (PUL) using the UroLift System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a prostatic urethral lift (PUL) using the 
UroLift System.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on May 30, 
2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not have to pay 
make this copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for physical therapy. This item/service falls within the outpatient 
rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a $20 copayment for a physical therapy visit. Therefore, we 
decided that the Plan does not have to waive the copayment for physical therapy provided on May 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 29, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for ambulance services. 
 
You have been asked to pay a $175 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on July 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for June 30, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 20611 
provided on June 30, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99214 billed for 
June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 5, 2023, billed with 
procedure code 12001-XU. 
 You asked the Plan to pay for the practitioner 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 12001-XU is a column II code to column I code 11012; however, 
12001-XU 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the procedure report describes an 
open fracture site was debrided and irrigated with closure. In this case, simple repair would be included in the 
primary procedure. Procedure report does not support simple closure as an unusual non-over lapping service. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 5, 2023, billed with procedure code 
12001-XU.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service June 8, 2023. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and prosthetic devices 
provided on August 19, 2023. 
 
You asked the Plan to waive the cost share for an office visit and prosthetic devices. You say that you disagree 
with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services/specialist and a 20% coinsurance for prosthetic devices.  
 
You have been asked to pay a $35 copayment for an office visit and a 20% coinsurance for prosthetic devices. 
The total allowed amount for the prosthetic device is $217.05, you are being asked to pay $43.41 ($217.05 x 20% = $43.41). The total amount you are being asked to pay $78.41 ($35 + $43.41 = $78.41). This item/service 
falls within the physician/practitioner services/specialist and prosthetic devices benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for an office visit and prosthetic devices provided on August 19, 2023.