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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support necessity for admission to an IRF. The 
complexity of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) does not require 
an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The enrollee's 
rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 
facility.  
 
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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service March 28, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services and assessment provided on March 16, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician services and assessment provided on 
March 16, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 for date of 
service February 23, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. 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. 
 
We find that codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, the 
documentation shows that Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by 
any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); 
and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed. This means there 
is more appropriate codes to be billed for the services rendered. Therefore, codes 96365, 96366, and 96521 are 
not supported. The documentation indicates that Nova R was administered via intravenous treatment. There is a more appropriate code to be billed for this service; therefore, code J1817 is not supported. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 96365, 96366, 96521, and J1817 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, 
96521, and J1817 for date of service February 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
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 that you do not have documented skilled nursing or skilled therapy needs. Your care 
needs can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on March 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed 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. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the lab order does not 
specify what test is being performed. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(81479) provided on March 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from November 26, 2022, 
to December 20, 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 the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 26, 2022. The NOA was not received by the Plan until March 
15, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from November 26, 2022, to December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97814, 97813, and 99213 billed for August 
17, 2022, to October 31, 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 procedure codes 97814, 97813, and 99213 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 97813 is acupuncture, 1 or more needles; with electrical 
stimulation, initial 15 minutes of personal one-on-one contact with the patient. The definition of code 97814 is 
acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one 
contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary 
procedure). The definition of code 99213 is office or other outpatient visit for the evaluation and management 
of an established patient, which requires a medically appropriate history and/or examination and low level of 
medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date 
of the encounter.  
 
We find that CPT codes 97814 and 97813 are not supported in the medical record. Specifically, there is no 
documentation of the time of personal one-on-one contact spent with the patient to support code 97813. Given 
that the primary procedure code 97813 is not supported, the add-on code 97814 is also 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, we have confirmed that code 99213 
is a column II code to column I code 97813. 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. 
 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 97814, 97813, and 99213 billed 
for August 17, 2022, to October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (98941, 98945) provided on March 8, 
2023. 
 
You asked the Plan to pay for the chiropractic services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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 98941 & 98945 is not supported in the medical record. Specifically, the claim did not 
include a valid diagnosis code. Diagnosis codes M54.51 (Vertebrogenic low back pain) and S39.012A (Strain 
of muscle, fascia and tendon of lower back, initial encounter) have an exclude note and should not be billed 
together. Based on this information, we decided that Medicare rules for coverage of the chiropractic services 
have not been met. Therefore, we decided that the Plan does not have to pay for chiropractic services (98941, 
98945) provided on March 8, 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 you would like the IRF admission request to be 
approved so you can regain your strength and mobility. 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 that you do 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the multiaxial ankle with swing phase active 
dorsiflexion feature (L5968) and flex-walk system lower extremity prostheses (L5981). 
 
You asked the Plan to pre-approve the prosthetic parts . You say that the enrollee cannot wear the new 
prosthetics received on February 15, 2023, due to the feet not working appropriately. The Plan denied your 
request. The Plan says the current prosthesis is still under warranty. Medicare does not cover replacement of 
items that are still under manufacturer's warranty. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The enrollees current foot, Ossur Proprio has a 36-month warranty. 
The current prosthesis is still under warranty. Medicare does not cover replacement of items that are still under 
manufacturer's warranty.  Based on this information, we decided that Medicare rules for coverage of the 
prosthetic parts have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
multiaxial ankle with swing phase active dorsiflexion feature (L5968) and flex-walk system lower extremity 
prostheses (L5981).
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbar facet joint radiofrequency ablation (RFA) procedure 
(64635, 64636). 
 
You asked the Plan to pre-approve a lumbar facet joint RFA procedure. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that thermal RFA 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 a lumbar facet joint RFA procedure. 
Our reviewer says that the services are medically necessary. Our physician reviewer found the request meets all 
of the coverage criteria and is 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 a lumbar facet joint RFA procedure have been met. Therefore, we decided that 
the Plan has to pre-approve a lumbar facet joint radiofrequency ablation (RFA) procedure (64635, 64636).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic analysis of a cochlear implant provided on 
November 18, 2022. 
 
You asked the Plan to pay for the diagnostic analysis of a cochlear implant. You say that you are appealing the 
denial with supporting documentation. 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 the diagnostic analysis 
of a cochlear implant provided on November 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment billed with code G2067 
provided on February 15, 2023. 
 
You asked the Plan to pay for procedure code G2067. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the medication treatment was not billed by a 
Medicare-enrolled Opioid Treatment Program (OTP) provider. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
  
We looked at the file and Medicare rules. The file shows that code G2067 was not billed by a provider enrolled 
in the Medicare program as an OTP provider. The record does show that you are SAMHSA certified for the 
OTP program, however, the billing National Provider Identifier (NPI) on the claim is not enrolled in the 
Medicare program. Providers must also be enrolled in the Medicare program to bill these codes for OTP 
services. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment billed 
with code G2067 provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6752) for teeth numbers 29, 32, 18 
and 20 and a false tooth (D6242) for bridge for teeth 30, 31, and 19. 
 
You asked the Plan to pre-approve a retainer crown (D6752) for teeth numbers 29, 32, 18 and 20 and a false 
tooth (D6242) for bridge for teeth 30, 31, and 19. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says these services were denied do to not meeting the criteria for coverage.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a retainer 
crown (D6752) for teeth numbers 29, 32, 18 and 20 and a false tooth (D6242) for bridge for teeth 30, 31, and 
19 when the services are medically necessary and reasonable.  
 
 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 retainer crown (D6752) for teeth 
numbers 29, 32, 18 and 20 and a false tooth (D6242) for bridge for teeth 30, 31, and 19. Our reviewer says that 
the with the documentation provided, this does not meet the criteria. Our physician reviewer found that 
according to the plan, fixed bridges may be covered to replace two adjacent missing mandibular anterior teeth 
or a single missing maxillary anterior tooth when there are no missing posterior teeth. Our physician reviewer 
also found that a review of the documentation indicates the presence of a bridge replacing posterior teeth 
numbers 30 and 31. Missing tooth number 19 is a posterior tooth. There was no indication why the bridge 
replacing missing teeth numberss 30 and 31 needs replacement.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a retainer crown (D6752) for teeth numbers 29, 32, 18 and 20 and a false tooth 
(D6242) for bridge for teeth 30, 31, and 19 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a retainer crown (D6752) for teeth numbers 29, 32, 18 and 20 and a false tooth (D6242) 
for bridge for teeth 30, 31, and 19.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT) pump. 
 
You asked the Plan to pre-approve (NPWT) pump. You say that it is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria due to lack of documentation to support use of 
wound vac for longer than 4 months. 
 
The Plan follows Medicare rules. Medicare rules say that 4 months (including the time NPWT was applied in 
an inpatient setting prior to discharge to the home) have elapsed using a NPWT pump in the treatment of the 
most recent wound. 
 
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 (NPWT) pump. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee does not meet criteria due to 
lack of documentation to support the use of wound vac for longer than 4 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of (NPWT) pump have not been met. Therefore, we decided that the Plan does not 
have to pre-approve negative pressure wound therapy (NPWT) pump.