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

We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with multiple power options (K0862) and additional items and accessories (codes E2311, E2313, E2377, E2363 x2, E1028, E1007, E2620, E0955, E1012, K0040 x2, E2607, and E1028).

You asked the Plan to pre-approve a group 3 heavy duty power wheelchair and additional items and accessories. You say that the records provided support the need for the items in dispute. The Plan denied your request. The Plan says the patient does not have medical need for multiple power options available with a K0862 group 3 power wheelchair. The Plan also says an expandable controller, harness and electronics are not medically needed.

The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options (such as code K0862) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied.

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 heavy duty power wheelchair and additional items and accessories. Our reviewer says that the group 3 power wheelchair with power tilt and recline and power elevating leg rests is not medically necessary. Our physician reviewer found the patient is non-ambulatory and cannot use a cane or walker for mobility. They cannot functionally propel a manual wheelchair due to upper extremity weakness and lack of endurance. The patient cannot operate a power scooter due to an inability to independently transfer. Our reviewer found that the patient requires a power wheelchair for mobility and accomplishing their daily activities. However, the clinical documentation is insufficient why a lower-level power wheelchair would not suffice for their needs versus a group 3 power wheelchair. There is inadequate clinical documentation regarding why the patient requires power tilt and recline and cannot perform pressure relief. Our physician reviewer found that the patient has no history of skin breakdown and has 3 out of 5 motor strength in the upper extremities. The patient is noted to have normal sitting balance and does not have complex seating needs. Our reviewer also found that there is no significant lower extremity edema or spasticity that would require power elevating leg rests.

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 heavy duty power wheelchair and additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with multiple power options (K0862) and additional items and accessories (codes E2311, E2313, E2377, E2363 x2, E1028, E1007, E2620, E0955, E1012, K0040 x2, E2607, and E1028).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection provided on May 16, 
2023. 
 
You asked the Plan to waive the coinsurance for the drug injection. You say that you want to appeal this 
coinsurance amount. 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 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the drug injection. This item/service falls within the Medicare Part B drugs 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. The total you owe is $216.53 ($1,082.63 allowed amount x 20% coinsurance = $216.53). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the drug injection provided on 
May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 15273 and 15274 rendered on August 11, 
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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 15273: 
 
Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq 
cm; first 100 sq cm wound surface area, or 1% of body area of infants and children  
CPT 15274: 
 
Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq 
cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of 
infants and children, or part thereof (List separately in addition to code for 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 procedure report does include 
sufficient documentation to verify the wound surface. 
 
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 procedure codes 15273 and 15274 rendered on August 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this due to 
worsening heart failure. The Plan denied your request. The Plan says the enrollee's body-mass index (BMI) is 
greater than 25 and there is no documentation of a chest circumference of less than 65 inches at the axillary 
level. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes to establish the value of CardioMEMS in patient management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat bilateral radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the repeat RFA. You say that this is necessary to treat the enrollee's pain. 
The Plan denied your request. The Plan says the notes do not show the enrollee had much relief from the initial 
treatment. The Plan also says there is no record of physical therapy in the last few years. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint radio frequency ablation 
(RFA) at the same anatomic site is considered medically reasonable and necessary provided the patient had a 
minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent 
improvement in the ability to perform previously painful movements and activities of daily living (ADLs) as 
compared to baseline measurement using the same scale. 
 
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 repeat RFA. Our reviewer says that 
the request for repeat RFA is not medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee had very little relief from the prior RFA at the requested levels. Therefore, 
the reviewer found that the request for repeat RFA 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 repeat RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat bilateral radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 3, 2023, billed with 
procedure codes 22853, 22830-59, and 63012-59. 
 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 codes. 
 
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 codes 22830 and 63012 are column II codes to column I code 22633, and 
code 22853 is a column II code to column I code 22849; however, 22830 and 63012 were billed with a 
modifier. Code 22853 was not 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 codes. Our reviewer found the operative report describes exploration 
of arthrodesis at L3-L4 and L4 and L5, as well as procedures performed in same anatomical area.  CPT codes 
22830 and 63012 shall not be reported with another procedure of the spine in the same anatomic area. 
Therefore, these procedures were unbundled. 
 
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 April 3, 2023, billed with procedure codes 
22853, 22830-59, and 63012-59.
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 this care to achieve maximum 
function. The Plan denied your request. The Plan says the enrollee no longer requires SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. 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 procedure code 99236 for date of service February 13, 2023. 
 
You asked the Plan to pay for procedure code 99236. 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 99236 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 85 minutes must be met or exceeded. 
 
 
 We find that CPT code 99236 is not supported in the medical record. Specifically, the submitted medical 
records do not include an observation or inpatient care note for the billed date of service. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99236 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99236 for date of service February 
13, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes Q0092 and R0070 billed for date of service May 17, 
2023. 
 
You asked the Plan to pay for the billed services. You say that services are provided at the enrollee's location. 
The Plan denied your request. The Plan says that the billed codes 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.  
 
We find that CPT codes Q0092 and R0070 are supported in the medical record. The file shows that a facial x-
ray was provided. Carriers must pay a set-up component for each radiologic procedure under code Q0092. The 
transportation component, R0070, represents the transportation of the equipment for service to one person. The 
Plan has not shown that the x-ray equipment was stored at the location where the x-rays were provided. Based 
on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the 
Plan has to pay for procedure codes Q0092 and R0070 billed for date of service May 17, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95819 billed for date of service March 16, 
2023. 
 
You asked the Plan to pay for procedure code 95819. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this code is not supported in the records provided. 
 
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 95819 is electroencephalogram (EEG); including 
recording awake and asleep. 
 
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 95819. Our reviewer says that the documentation is not specific enough to verify whether or not the components of 95819 are present. Our 
reviewer found the EEG report mentions measurements during sleep, but does not mention whether or not the 
enrollee was awake for any of the procedure. If the measurements were only taken when the enrollee was 
asleep, there is a more specific code for this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95819 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95819 billed for date of service March 16, 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 enrollee meets all applicable Medicare criteria 
for admission to an acute rehabilitation unit. The Plan denied your request. The Plan says the IRF services 
requested 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 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 16, 
2023. 
 You asked the Plan to pay for procedure code 81456. The Plan denied your request. The Plan says payment for 
code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary level care provider office visit with the 
requested provider. 
 
You asked the Plan to pre-approve a tertiary level care provider office visit with the requested provider. You 
say that you have been treated by this oncologist and you have been following up with them for many years. 
You say that this provider knows about your melanoma cancer and has been monitoring your condition. The 
Plan denied your request. The Plan says the requested tertiary level care provider office visit 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 tertiary level care provider office 
visit. Our reviewer says that the requested tertiary level care provider office visit is not considered medically reasonable and necessary. Our physician reviewer found that you need observation only and perhaps imaging. 
You do not require tertiary level of care and you can be safely managed by the Plan approved oncologist. 
 
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 tertiary level care provider office visit have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a tertiary level care provider office visit with the requested 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 rendered on January 23, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99152-GC (1 units) remains 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the submitted 
medical records do not indicate the intra-service time for moderate sedation services. Information in the 
provider's medical record should contain documentation (such as, monitoring of vital signs, oxygen saturation, 
etc) to support that an independent, trained observer was present during the procedure. The documentation 
submitted did not indicate the presence of an independent trained observer during the procedure for the billed 
services. There was documentation that Midazolam and Fentanyl were administered, however, there was no 
anesthesiology record documenting intraoperative/intra-procedural monitoring of this patient (including blood 
pressure, heart rate, respiratory rate, electrocardiogram, oxygen saturation). The review has determined that the 
use of CPT 99152 is not supported by the records provided. 
 
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 procedure code 99152 rendered on January 23, 2023.