Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic physical therapy. 
 
You asked the Plan to pre-approve aquatic physical therapy. You say that the aquatics physical therapy was 
progressing and helping with your lower back and hip. You also say that it helps you walk better without pain 
and now that you cannot have the therapy you are now regressing. The Plan denied your request. The Plan says 
it is agreed that you need to continue with aquatic exercise of walking and strengthening, but you can continue 
in a community pool. The Plan also says the therapeutic exercises you were receiving at aquatic therapy 
previously consist of walking stretching, and other activities that you can easily do on your own. 
 
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 aquatic physical therapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have previously been treated with outpatient aquatic therapies and should be 
independent with a home exercise program. There is no documentation of a recent injury or decline in function. 
Our reviewer found that the additional therapy services are not an appropriate duration and frequency for 
treatment of your medical condition, and therefore are not medically necessary. Our physician reviewer also 
found that you can continue the home exercise program in a community 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 aquatic physical therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve aquatic physical therapy.
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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 you are medically stable and does not need physician supervision at least 3 times per 
week. You do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per 
week as the enrollee would not likely tolerate this level of therapy. The complexity of your nursing, rehab, and 
medical, needs (combined complexity) does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative 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 K3 lower limb prosthetic foot (L5981, L5986). 
 
You asked the Plan to pre-approve K3 lower limb prosthetic foot. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that specific criteria must be met for some features. 
 
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 K3 lower limb prosthetic foot. Our 
reviewer says that the documentation does not support that the enrollee is able to ambulate at a K3-functional 
level. Our physician reviewer found there is no clear documentation to support the enrollee requires upgraded 
components including a K3-level prosthetic foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of K3 lower limb prosthetic foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve K3 lower limb prosthetic foot (L5981, L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99220 and 99226 billed for October 5, 
2022, to October 6, 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 99220 and 99226 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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
The definition of code 99226 is subsequent observation care, per day, for the evaluation and management of a 
patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed 
examination; Medical decision making of high complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the 
problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a 
significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the 
patient's hospital floor or unit. 
 
We find that CPT codes 99220 and 99226 are not supported in the medical record. Specifically, the records 
show that the enrollee was not under observation status for the dates of service at issue. 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 99220 and 99226 billed for October 5, 2022, to 
October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel provided on 
December 30, 2022, and billed with multiple codes including 87481 and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the urine PCR (polymerase chain reaction) panel provided on December 30, 2022, and billed with multiple 
codes including 87481 and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (0241U) provided on December 7, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (0241U) 
provided on December 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Minuteman G3R Interspinous 
device to L4-L5. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Minuteman device is experimental. More research is needed for this device. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantation of the Minuteman G3R Interspinous device to L4-L5.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 5, 2022, to 
March 7, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically 
necessary for the enrollee. The Plan denied your request. The Plan says that prior authorization was not 
obtained. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the provided documentation indicates the enrollee was treated with intravenous fluids, 
antibiotics, and Depakote. Therefore, the reviewer found that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 5, 2022, to March 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for September 11, 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 code 12011 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 12001 is simple repair of superficial wounds of scalp, 
neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less. 
 
We find that CPT code 12001 is not supported in the medical record. Specifically, the records show that a 
simple laceration repair of the left eyebrow was performed and there is a more appropriate code for these 
services. 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 12001 billed for 
September 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies (A4221, A4222) provided on August 17, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the supplies (A4221, A4222) provided on August 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan (78803). 
 
You asked the Plan to pre-approve a SPECT scan. You say that you have a tremor in your jaw, not an essential 
tremor. The Plan denied your request. The Plan says you do not meet the guidelines for coverage. 
 
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 SPECT scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you were being seen for a neurology evaluation. Your clinical presentation on examination was 
readily consistent with the clinical manifestations of Parkinson's Disease (PD). Our reviewer found that the 
current diagnostic criteria for PD indicate that such a diagnosis can be made on clinical examination alone. 
There is not a need for any imaging studies to be utilized in order to establish such a diagnosis. Our physician 
reviewer found that the requested imaging study would not be the most appropriate service which could be 
provided to you at this time. Such services would also otherwise exceed your clinical needs. Our reviewer 
found that in as much, medical necessity cannot be established 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 a SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single-photon emission computerized tomography (SPECT) scan (78803).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 51798 billed for July 6, 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 services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only stand alone codes. 
 
We looked at the file and Medicare rules. Billed procedure code 51798 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for procedure code 51798 billed 
for July 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm or disorder, 51 or greater genes (81455) provided December 16, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that molecular testing was requested directly 
from the treating physician who makes the professional determination of diagnosis and medical necessity to 
successfully treat the enrollee. The Plan denied your request. The Plan says that charges for services or supplies 
determined by the Plan to be experimental or investigational are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a right lung neoplasm. The enrollee has lung cancer 
metastatic to bone. The review has determined that the items/services at issue in this case 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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for the targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm or disorder, 51 
or greater genes (81455) provided December 16, 2021.  
 
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 99497 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99497 is bundled into payment for code 99291. 
 
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 99497 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not payable. 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 99497 billed for date of service July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical nerve stimulator provided on November 17, 
2022. 
 
You asked the Plan to pay for the nerve stimulator. The Plan denied your request. The Plan says the 
documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the date of service in question. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the electrical nerve stimulator provided on November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87481, 
87491, 87496, 87500, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, 87798) provided on August 
22, 2022. 
 
You asked the Plan to pay for the urine PCR panel. 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 test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This was a panel that 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 (87481, 87491, 87496, 87500, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, 87798) 
provided on August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6196 billed for date of service December 1, 
2022. 
 
You asked the Plan to pay for procedure code A6196. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A6196 is considered bundled/excluded from payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code A6196 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6196 is not separately payable/excluded from payment. Based on this information, we 
decided that Medicare rules for coverage of procedure code A6196 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code A6196 billed for date of service December 1, 2022.