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

 
We decided that the Plan does not have to pay for procedure code 99291 billed for May 20, 2023, to May 22, 
2023. 
 
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 code 99291 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
a critical care visit of 30-74 minutes for each billed date of service. 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 code 99291 billed for May 20, 2023, to May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services related to end-stage renal disease (ESRD) 
provided on February 2, 2023, to February 28, 2023. 
 
You asked the Plan to pay for the ESRD-related services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related services. 
 The Plan must follow Medicare rules. Medicare rules state that all injectable drugs and biologicals and their 
oral or other form of administration, laboratory tests, supplies, and services provided for the treatment of ESRD 
are included in the ESRD PPS. Therefore, we decided that the Plan does not have to pay for the services related 
to end-stage renal disease (ESRD) provided on February 2, 2023, to February 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of the CardioMEMs 
device has not been demonstrated in the peer-reviewed literature. 
 
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 CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this device is considered investigational. Therefore, the reviewer found that the 
requested CardioMEMS device 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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this care to provide 
the additional recovery time to safely return home. The Plan denied your request. The Plan says the enrollee's 
needs can be managed at the current facility until they are more stable for transfer to another level of care. 
 
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 transfer to the LTACH is not medically necessary as the enrollee is not stable for 
transfer without a stable feeding source. The enrollee does not require services at the LTACH that are not 
already available at the current facility. Completion of treatment at the current facility is recommended.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on May 13, 2023, and billed with codes 87653, 87481, 87798, 87801, and 81003. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on May 13, 2023, and billed with codes 87653, 87481, 87798, 87801, and 81003.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on February 5, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81479) provided on February 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair (E0951, E0961, E0971, E0973, E0990, 
E2201, E2203, E2211, E2213, E2231, E2609, E2617, K0005, K0040). 
 
You asked the Plan to pre-approve a wheelchair. You say that the item is necessary. The Plan denied your 
request. The Plan says the enrollee lives in a skilled nursing facility. Therefore, the requested item is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a wheelchair (E0951, E0961, E0971, E0973, E0990, E2201, E2203, E2211, 
E2213, E2231, E2609, E2617, K0005, K0040).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from December 5, 2022, to 
December 12, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says that a post-service, post-payment clinical 
validation audit was performed to help ensure that the diagnosis codes on the claim supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were supported by the medical records. Our physician reviewer found that 
the enrollee meets the criteria for systemic inflammatory response syndrome. Therefore, diagnosis code A41.9 
is justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services rendered from December 5, 2022, to December 12, 2022.  
 
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: 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 admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says enrollee does not meet the Medicare criteria for 
admission to an IRF. The services the enrollee needs can be provided safely in other settings, for example, a 
skilled nursing facility (SNF), home with home health services or home with outpatient therapy.  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees 
medical problems are stable. The enrollee does not require treatment by multiple therapies. 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. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. The enrollee's rehabilitation needs can be safely provided in 
an alternate and low intensity setting such as in an SNF.  
 
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 pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve the nerve block. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says experimental and investigational procedures are not covered. 
 
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 nerve block. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 
 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 1, 2023, to February 27, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing, drugs, biologicals, supplies, and other services.  
The Plan must follow Medicare rules. Medicare rules state that ESRD related laboratory services, drugs, 
biologicals, supplies, and other services are not separately payable. Laboratories should bill the facility directly 
for laboratory services as they are considered part of the composite rate. No other payment for these services is 
allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-
stage renal disease (ESRD) provided on February 1, 2023, to February 27, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with accessories (E0955, E0973, 
E1028, E2361, E2605, E2620, K0848). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with accessories. 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 power mobility devices 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 with 
accessories. Our reviewer says that the services are medically necessary. Our physician reviewer found 
provided records in this case document a mobility limitation is due to a congenital skeletal deformity 
(scoliosis). Records also document coverage criteria (a)-(e) for a PWC are met as well as a specialty evaluation 
by an independent physical therapist and a RESNA-certified Assistive Technology Professional. The requested 
accessories also meet LCD criteria for approval. 
 
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 with accessories have been met. Therefore, we 
decided that the Plan has to pre-approve a group 3 power wheelchair with accessories (E0955, E0973, E1028, 
E2361, E2605, E2620, K0848).   
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 procedure code G0447 billed for date of service February 8, 
2023. 
 You asked the Plan to pay for procedure code G0447. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code G0447 is bundled into payment for code 99214. 
 
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 G0447 
is a column II code to column I code 99214. 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 G0447 billed for date of service February 8, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the current medical literature does not consider this service to be 
standard medical treatment for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental/ investigational. It is the subject of ongoing 
clinical trials. Therefore, the reviewer found that the requested genicular nerve block is 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64454).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 36556 rendered on March 31, 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 that Current Procedural Terminology (CPT) code 36556 (1 Unit) 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 36556 is "Insertion of non-tunneled centrally inserted central venous catheter; 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 supported by the medical records. Our reviewer found that the documentation supports that the 
services in question were rendered and appropriately coded. There is satisfactory documentation that a central 
line was placed via the internal jugular vein. There is satisfactory documentation that the line was placed 
centrally.  As most central lines placed in the emergency room/intensive care unit are not placed under 
fluoroscopic guidance, the exact location of the tip cannot be documented, and it is not reasonable to require 
this information to justify billing.  However, in this case, there is x-ray documentation of the catheter tip in the 
right brachial-cephalic vein on a post operative chest x-ray confirming central placement. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 36556 rendered on March 31, 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve stab phlebectomies (37765, 37766). 
 
You asked the Plan to pre-approve the stab phlebectomies. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the records do not show that the enrollee's provider 
has addressed the reflux present in the left greater saphenous vein.  
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than 4 millimeters (mm) in diameter and if the patient remains symptomatic after a six-week trial of 
conservative therapy. 
 
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 stab phlebectomies. Our reviewer 
says that the requested stab phlebectomies are medically necessary. Our physician reviewer found here is 
satisfactory documentation that conservative efforts including the use of compression stockings was attempted 
for more than 6 weeks. The veins are documented to be greater than 4 mm in diameter. The enrollee remains 
symptomatic. The reflux noted in the saphenous vein is not associated with the veins in question and the 
provider documents that ablation of this vein may be excessive. Therefore, the reviewer found that the 
requested stab phlebectomies are 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 the stab phlebectomies have been met. Therefore, we decided that the Plan has 
to pre-approve stab phlebectomies (37765, 37766).  
 
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.