Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed. 
 
You asked the Plan to pre-approve the requested services. You say that you cannot pull yourself up when you 
are laying down. The Plan denied your request. The Plan says you do not meet the coverage criteria. 
 
The Plan follows 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 services. Our physician 
reviewer found that you are noted to have obesity and difficulty with mobility. There is insufficient clinical 
documentation regarding your level of mobility and function and if you require re-positioning while in bed due 
to an inability to perform weight shifts and re-positioning. You are noted to have a ventral wound, but this is 
due to your hernia versus a pressure wound. You also do not have a medical condition that would necessitate 
elevation of the head of bed, and you are not noted to have dyspnea when in bed. Therefore, the heavy duty 
extra wide hospital bed 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a heavy duty extra wide hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77427 billed for date of service May 15, 
2023. 
 
You asked the Plan to pay for the billed services. You say that 1 unit is equal to 5 fractions. The Plan denied 
your request. The Plan says the number of fractions was not billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 77427 is not supported. The submitted claim does not indicate the number of fractions 
for which payment is sought. 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 code 
77427 billed for date of service May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair options. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The file shows that a red power wheelchair cover shroud was requested. The item at issue in this appeal does 
not serve a purpose that is primarily medical in nature. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve 
wheelchair options.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches. You say that you 
are requesting an expedited appeal for the denial of the genicular nerve procedure. The Plan denied your 
request. The Plan says the service requested does not meet the requirements for approval. 
 
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 destruction by neurolytic agent, 
genicular nerve branches. Our reviewer says that the requested items/services are not considered medically 
necessary in this case. Our physician reviewer found this is an experimental/investigational therapy that 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 destruction by neurolytic agent, genicular nerve branches have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular 
nerve branches (64624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222-HE billed for date of service June 17, 
2023. 
 
You asked the Plan to pay for procedure code 99222-HE. You say that these services should be paid as code 
99223-57. The Plan denied your request. The Plan says services billed with the -HE modifier are not payable 
by Medicare. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99222-HE have not been met. Specifically, services reported with modifier -HE are 
not covered or not payable by Medicare. The documentation provided supports that 99222-HE was reported on 
this claim, and there is no evidence that 99223-57 was billed by this provider. If a corrected claim is required, 
the provider should submit one directly to the Plan. Therefore, we decided that the Plan does not have to pay 
for procedure code 99222-HE billed for date of service June 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on December 21, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you have no idea who called 
for the ambulance, and they didn't provide any service. 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 December 21, 2022. 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 
December 21, 2022.
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 an IRF admission is necessary because the enrollee 
has a serious, life threatening constellation of acute medical problems that left them at a functional status below 
their baseline. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to an IRF.  
 
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's 
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. Medically necessary 
care can be provided in a different level of care. 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.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revision of total knee arthroplasty (27487). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the enrollee has had more pain and 
swelling of the right knee. You say that the enrollee reports that the right knee never really got pain-free from 
surgery. You also say that the enrollee has swelling. The Plan denied your request. The Plan says there is no 
documentation of a loose or fractured implant in the enrollee's knee. The Plan says that there is no arthritis of 
the other area of the knee. 
 
The Plan follows Medicare rules. Medicare rules say that a total knee arthroplasty (TKA) medically reasonable 
and necessary when certain 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 the outpatient procedure. Our reviewer 
says that the requested revision of total knee arthroplasty is not medically reasonable or necessary. Our 
physician reviewer found the detailed documentation is not evident regarding advanced joint disease 
demonstrated by radiographic findings. The noted x-rays did not document any deficits in the right knee. There 
are no distinct structural abnormalities nor are there any signs of loosening or hardware failure of the right 
knee. Additionally, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, 
less invasive conservative care measures is not evident. Therefore, the reviewer found that the requested 
revision of total knee arthroplasty 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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a revision of total knee arthroplasty (27487).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (29999) provided on February 28, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 29999 is "Unlisted procedure, arthroscopy". 
 
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 use of code 29999 is 
not supported by the records provided. Our reviewer found that the operative report does not include sufficient 
documentation to verify the procedure reported with an unlisted procedure code, and therefore cannot be 
verified. When reporting an unlisted procedure, documentation should be clear for the service reported.  
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 the services (29999) provided on February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator billed with code E1392 for 
date of service March 11, 2023. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that J44.9 has an Excludes1 note in relation to J43.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not 
have to pay for the portable oxygen concentrator billed with code E1392 for date of service March 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 8, 2023, billed with 
codes 87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 87529, and 87653. 
 
You asked the Plan to pay for the genetic testing billed. You say that the coding is approved by Medicare. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that a wound panel test was provided. We looked at the file and Medicare rules. This NGS panel 
was not billed with a single code as required. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing provided on June 8, 2023, billed with codes 87481, 87641, 87798, 87640, 87500, 
87651, 87471, 87493, 87529, and 87653.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service March 28, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services were billed with an incorrect place of service. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this service was billed with 
place of service 22 (On Campus-Outpatient Hospital). It is not appropriate to bill an emergency department 
code with this place of service. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99285 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99285 for date of service March 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 in consideration of the enrollee's prior medical 
history, active comorbidities, and risk for medical instability while increasing activity, the IRF setting is the 
most appropriate to reach the desired outcomes. The Plan denied your request. The Plan says the enrollee's 
condition does not meet Medicare guidelines for admission to an IRF.  
 
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's medical complexity does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The enrollee does not require an intensive 
rehabilitation therapy, and it is unclear if they would tolerate it. There is not a reasonable expectation that the 
enrollee will be able to benefit from the intensive rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (97535) provided on February 20, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 97535 is "Self-care/home management training (eg, 
activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and 
instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 
minutes". 
 
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 use of code 97535 is not supported by the records provided. Our reviewer found that the record does not contain evidence that self-
care and activities of daily living teaching were performed for 15 minutes on the date of service in question. 
 
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 the services (97535) provided on February 20, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve next generation sequencing (genetic testing). 
 
You asked the Plan to pre-approve genetic testing. 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 genetic testing is 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 genetic testing. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the provided documentation did not 
describe the enrollee with recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Also, 
this test was not found to be FDA approved. Therefore, the NCD criteria for this test is not met at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve next generation sequencing (genetic testing).
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 you need to get intense therapy three hours a day to 
get back to your baseline before going back home. You say you live alone and need to continue your 
intravenous antibiotics. The Plan denied your request. The Plan says you do not meet Medicare guidelines for 
services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable, and there are no complex nursing or rehabilitation needs. 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.  
 
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.