Persius/hicric huggingface dataset:
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 enrollee deserves a chance at a higher level of 
care and intensive therapy to reach their desired goals. You say the enrollee is motivated and willing to work 
hard. 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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62322 billed for date of service December 9, 
2022.  
 
You asked the Plan to pay for procedure code 62322. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 62322 is 1. The MAI value for this code is 3. You billed 80 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 62322 have not been met.  Therefore, we decided that the 
Plan does not have to pay for procedure code 62322 billed for date of service December 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine injection on July 5, 2022. 
 
You asked the Plan to pay for Bupivacaine. You say that you have correctly billed the service at issue. The 
Plan denied your request. The Plan says the service at issue is included in the global package of a surgery or 
procedure on the same date of service. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (27096) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for Bupivacaine injection on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
14, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Monitor test (0013M) provided on November 
18, 2022. 
 
You asked the Plan to pay for the Cxbladder Monitor test. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Monitor test (0013M) provided on November 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arterial catheter placement (36247). 
 
You asked the Plan to pre-approve the arterial catheter placement . You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 arterial catheter placement. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this service is considered experimental. 
 
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 arterial catheter placement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the arterial catheter placement (36247).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95955, 95886, 95937, 95908, and 95927 
billed for date of service January 29, 2021. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed services are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that the enrollee received intraoperative neuromonitoring. We find that CPT codes 95886, 
95937, 95908, and 95927 are not separately payable when performed during anesthesia. We find that CPT code 
95955 is not supported in the records. The records do not show that this was an unusual non-overlapping 
service. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95955, 95886, 95937, 
95908, and 95927 billed for date of service January 29, 2021.
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 servicesThe Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable gaseous oxygen system (E0431). 
 
You asked the Plan to pre-approve a portable gaseous oxygen system. 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 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable gaseous oxygen system Our 
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) and is on continuous home 
oxygen. The enrollee already has an approval in place for a portable oxygen system, and there is no need for a 
second system. This issue is not addressed in the most recent clinical visit note from February 17, 2023. 
 
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 portable gaseous oxygen system have not been met.  Therefore, we decided 
that the Plan does not have to pre-approve a portable gaseous oxygen system (E0431).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs therapy so she can walk again. 
The Plan denied your request. The Plan says the enrollee's benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from January 17, 
2023, to May 30, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on February 10, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that you say you rely on facility staff to verify 
eligibility and obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  

The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit for 
evaluation provided on February 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64999 billed for date of service February 16, 
2023. 
 
You asked the Plan to pay for procedure code 64999. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 0 for CPT code 64999. This 
means there is only technical component for the CPT code. The concept of professional component/technical 
component does not apply since physician services cannot be split into professional and technical components. 
Modifiers 26 and TC cannot be used with this code. This code is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of procedure code 64999 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 64999 billed for date of service 
February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight psychotropic test (81479) provided June 14, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the basis of the denial is that GeneSight 
Psychotropic is not medically necessary. This decision is incorrect based on current publications and medical 
practice. The Plan denied your request. The Plan says the services do not meet the Medicare coverage criteria.  
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 pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the documentation does not support that the GeneSight psychotropic testing provided on for the 
purpose of medication selection offers a benefit over selection of medications based on contemporary 
evidence-based medication selection protocols.  The case file does not contain sufficient documentation 
regarding which specific medications the enrollee has tried and failed or were to be augmented or discontinued. 
There was not documentation that the ordering provider considered non-genetic factors to make the preliminary 
drug selection, or that the provider made a personalized decision as detailed in the LCD. Although the order 
stated that the enrollee had failed treatment with several medications and that several medications were being 
considered for augmentation or starting/switching to and dosage adjustment, there is no specific documentation 
in the provided medical records. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for GeneSight psychotropic test (81479) provided June 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 on 
November 21, 2022. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 7, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met.  Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 on 
November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2603, and K0842). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. 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 follows Medicare rules. Medicare rules say that power wheelchairs are covered when specific criteria 
are met. 
 
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 group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary/. Our physician reviewer found the 
criteria for a group 3 wheelchair are not met as the enrollee does not have high risk for skin disease, does not 
use a catheter and does not have spasticity. 
 
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 group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0955, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, E2603, and K0842).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service December 1, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is 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.  
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 code 99223. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the provided records in this case do not 
document all of the following elements: a chief complaint, an extended history of present illness, a review of 
all additional body systems and a complete past, family and social history. A comprehensive history is not 
supported. Therefore, code 99223 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 procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 for date of service December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections.  
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injections do not meet the 
Medicare LCD coverage criteria. The enrollee had last injection on January 20, 2023, with 50% pain relief. 
 
The Plan follows Medicare 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 pre-approve facet joint injections. Our reviewer says 
that the requested facet joint injections are not considered medically necessary this case. Our physician 
reviewer found that in this case, the enrollee had 50% improvement from the injection January 20, 2023. The 
guidelines recommend at least 80% improvement. The review has determined that  the requested facet joint 
injection does not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.