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

 
We decided that the Plan does not have to pay for practitioner services provided on May 5, 2023, billed with 
procedure codes A5500-RT-KX, A5500-LT-KX, A5512-RT-KX (3 Units) and A5512-LT-KX (3 Units). 
 
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 the documentation requirements have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid proof of delivery for the supplies provided in this case. Documentation 
provided does not include a dated signature to verify that the enrollee received the items at issue. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for practitioner services provided on May 5, 2023, billed with 
procedure codes A5500-RT-KX, A5500-LT-KX, A5512-RT-KX (3 Units) and A5512-LT-KX (3 Units).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed-height hospital bed. 
 
You asked the Plan to pre-approve the requested bed. The Plan denied your request. The Plan says the coverage 
criteria have not been met.  
 The Plan must follow Medicare rules. Medicare rules say that hospital beds are only covered under certain 
medical indications.  
 
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 requested bed. Our physician 
reviewer found that the enrollee is non-weightbearing in the right lower extremity due to a metatarsal fracture 
that requires surgery. She is not noted to have difficulty with transfers or bed mobility and has full motor 
strength in her bilateral upper limbs and left lower extremity. There is no indication that the enrollee requires 
positioning that is not feasible with an ordinary bed. The enrollee does not have a medical condition that would 
require elevation of the head of bed, such as heart failure or chronic obstructive pulmonary disease. There is 
not stated need for traction equipment. Therefore, the requested fixed height hospital bed (E0250) is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fixed-height hospital bed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transport services provided on March 15, 
2023. 
 
You asked the Plan to pay for the non-emergency transport services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee did not meet the criteria for medical 
necessity. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
 
 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 non-emergency transport services. Our 
reviewer says that the non-emergency transport was not medically necessary. Our physician reviewer found the 
enrollee was not bedridden, as evidenced by their ability to sit in a dialysis chair, stand-pivot-transfer, and sit in 
a wheelchair. The enrollee did not require the expertise of trained personnel or the equipment available only on 
an ambulance in order to effectuate a safe transport. Transportation could have been provided by other means 
without endangering the enrollees condition. 
 
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 non-emergency transport services have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergency transport services provided on March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cologuard testing. 
 
You asked the Plan to pay for Cologuard. You say that you have never had a Cologuard test and have not had a 
colonoscopy in more than 10 years. The Plan denied your request. The Plan says you are not within the covered 
age range for Cologuard testing. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard testing is only covered for enrollees 
who meet certain criteria, including being within the age range of 50 to 85 years.  
 
We looked at the file and Medicare rules. You are not within the covered age range of 50 to 85 years. Based on 
this information, we decided that Medicare rules for coverage of Cologuard have not been met. Therefore, we 
decided that the Plan does not have to pay for Cologuard testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 27, 2022, to 
November 2, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that acute 
respiratory failure with hypoxia is the correct principal diagnosis. The Plan denied your request. The Plan says 
the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported 
inpatient hospital services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, J96.01, defined as acute 
respiratory failure with hypoxia. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the services at issue in this case were not 
supported by the medical records. Our physician reviewer found the enrollee was hospitalized with stroke-like 
symptoms. In the evenings, the enrollee showed signs of delirium and sun-downing. Five days after 
hospitalization, the enrollee had an acute, overnight, respiratory event, presumed to be aspiration. The enrollee 
was given breathing treatments, oxygen and antibiotics. There is no evidence that the enrollee had respiratory 
failure. As such, the billing of J96.01 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 27, 2022, to November 2, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
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 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not specify any acute clinical conditions, changes in medication or plan of care and recent 
sessions refused by the patient. The records do not show that 2 additional home health skilled nursing visits are 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or 
to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interspinous stabilization device 
(22869, 22870). 
 
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 in this case, the Food and Drug Administration states that an interspinous spacer is indicated to treat 
skeletally mature patients suffering from pain, numbness, and/or cramping in the legs (neurogenic intermittent 
claudication) secondary to a diagnosis of moderate lumbar spinal stenosis, with or without Grade 1   
 
 
 
spondylolisthesis, confirmed by x-ray, magnetic resonance imaging (MRI), and/or computed tomography (CT) 
evidence of thickened ligamentum flavum, narrowed lateral recess, and/or central canal narrowing. An 
interspinous spacer is indicated for those patients with impaired physical function who experience relief in 
flexion from symptoms of leg/buttock/groin pain, with or without back pain, who have undergone at least 6 
months of non-operative treatment. The enrollee indicates that she has chronic low back pain and lumbar spinal 
stenosis with claudication. The record indicates that the enrollee has had imaging studies demonstrating severe 
spinal and foraminal stenosis at the levels requested for treatment. 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of an interspinous stabilization device (22869, 22870).
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 for 
the enrollee to receive the level of care needed. The Plan denied your request. The Plan says the enrollee can 
reasonably receive their continued care needs in another 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 enrollee's needs are currently being met at the hospital. Lateral transfer would not 
benefit the enrollee at this time. LTACH placement 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415, 81002, G0109 and 95921 billed for 
date of service April 11, 2023. 
 
You asked the Plan to pay for procedure codes 36415, 81002, G0109 and 95921. You say that these services 
were necessary and are represented in the medical records. The Plan denied your request. The Plan says these 
codes 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. 
 
In this case, the CPT code manual definition of code 36415 is collection of venous blood by venipuncture. The 
CPT code manual definition of code 81002 is urinalysis, by dip stick or tablet reagent for bilirubin, glucose, 
hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these 
constituents; non-automated, without microscopy. The CPT code manual definition of code G0109 is diabetes 
outpatient self-management training services, group session (2 or more), per 30 minutes. The CPT code manual 
definition of code 95921 is testing of autonomic nervous system function; cardiovagal innervation 
(parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with 
recorded R-R interval, Valsalva ratio, and 30:15 ratio. 
 
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 36415, 81002, G0109 and 95921. Our 
reviewer says that these codes are not supported in the records provided. Our reviewer found that the record 
does not mention collection of blood by venipuncture. There are no results showing that a urinalysis was 
performed. There is no documentation of diabetes serf-management training services performed for 30 minutes. 
Lastly, although there is a printout of autonomic balance and accelerated photoplethysmography, there is no 
physician report and interpretation supporting that the physician performed this 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 procedure codes 36415, 81002, G0109 and 95921 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 36415, 81002, G0109 and 95921 
billed for date of service April 11, 2023.
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 the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM. Our physician reviewer 
found that the record does not indicate the enrollee is on insulin or has a history of problematic hypoglycemia. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an office visit provided on June 28, 2023. 
 
You asked the Plan to reduce the copayment for an office visit. You say that you thought that the provider was 
in-network. 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 $65 
copayment for each out-of-network visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $65 copayment for an office visit. This item/service falls within the each out-of-
network visit or consultation in an outpatient location with a specialist 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 reduce the copayment for an office visit provided on June 28, 2023.
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, The Plan 
denied your request. The Plan says ongoing skilled care can be provided in another setting.  
 
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 enrollee does not require treatment by multiple therapies. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care (99233) 
provided from February 28, 2023, to March 6, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care. You say that there is sufficient 
documentation in the record that supports the enrollee's initial findings were consistent with a broad range of 
high-risk diagnoses requiring medical decision making of high complexity. The Plan denied your request. The 
Plan says the original billed CPT code 99233 is not supported by the documentation 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. 
 
 
 
 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 subsequent hospital inpatient or observation care. Our 
reviewer says that the service does not meet criteria for payment on this claim. Our reviewer found based on 
the documentation provided, no records have been submitted for February 28, 2023, March 1, 2023, or March 
2, 2023. As such, the billing of code 99233 for these days is not supported. The records for March 3, 2023, 
March 4, 2023, March 5, 2023, and March 6, 2023, do not contain medical decision making of high 
complexity. Additionally, these records do not note the amount of time spent providing care to the enrollee. As 
such, the billing of CPT 99233 for these days is 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 subsequent hospital inpatient or observation care have not been met. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital inpatient or observation care (99233) 
provided from February 28, 2023, to March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you are requesting reconsideration 
and submitted medical records to support appeal. The Plan denied your request. The Plan says the request is not 
medically necessary because based on the medical literature, this procedure is considered experimental or 
investigational and has not been proven to be beneficial for the enrollee's condition. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has bilateral osteoarthritis of the knees. The enrollee has had physical 
therapy and steroid injections and visco supplementation. The enrollee has had multiple prior radiofrequency 
ablation procedures with good results, and which lasted greater than 6 months. This is considered experimental 
therapy and is the subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable 
and 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance, when performed (64624).