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

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E2361, 
E1007, E2620, E1012, E2377, E2313, E2311, E2603). 
 
 You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare 
guidance says that a group 3 PWC with multiple power options is medically necessary for individuals that 
require both power tilt and power recline. The notes do not show that the enrollee needs both of these power 
options. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that medical records from the treating practitioner do not support that 
the enrollee is high risk for skin breakdown (the enrollee walks short distances with a walker), has a history of 
pressure ulcer(s) or has had skin flap surgery. Medical records from the treating practitioner do not document 
the enrollee performs bladder self-catheterization or that the enrollee has increased muscle tone or spasticity to 
meet criteria for the power tilt and/or recline and thus the multiple power option base. As the requested 
wheelchair base does not meet Medicare coverage criteria, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E2361, E1007, E2620, 
E1012, E2377, E2313, E2311, E2603).
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 would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary.  
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 patient is highly motivated to participate in 
therapy and would benefit from acute inpatient rehabilitation. You also say that the patient is making study 
progress in occupational therapy and requires intensive multi-disciplinary intervention. The Plan denied your 
request. The Plan says based on the available information, admission to an IRF is not reasonable and necessary.  
 
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 patient's nursing, medical and rehabilitation can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. Our reviewer also found that there is 
documentation that there is a reasonable expectation that this patient will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF, but the services required 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 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 an appliance identified with code E0667 for use with 
intermittent limb compression device. 
 
You asked the Plan to pre-approve an appliance. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the enrollee did not meet criteria for the requested appliance. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. The rules also say that PCD related accessories (E0667) are eligible for reimbursement 
only when the appropriate, related base PCDs (E0650, E0651, E0652, E0675) meets the applicable coverage 
criteria for that type of PCD. The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Since the enrollee does not meet criteria for the PCD, the requested appliance/accessory is not 
covered. Therefore, we decided that the Plan does not have to pre-approve an appliance identified with code 
E0667 for use with intermittent limb compression device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29580 billed for date of service April 3, 
2023.  
 
You asked the Plan to pay for procedure code 29580. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29580 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29580 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29580 billed for date of service April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve wheelchair ramp. You say that you are in a wheelchair and personnel cannot 
assist you down the stairs. The Plan denied your request. The Plan says this item is intended for use outside of 
the home which is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies (A4595) provided on March 11, 2023. 
 
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 (A4595) provided on March 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS system (33289). 
 
You asked the Plan to pre-approve CardioMEMS system. You say that this service is necessary and will work 
well for you. The Plan denied your request. The Plan says this service is considered experimental, 
investigational or unproven and therefore 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 CardioMEMS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in your clinical 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 system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CardioMEMS system (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29540 billed for date of service May 24, 
2023.  
 
You asked the Plan to pay for procedure code 29540. You say that the enrollee has bilateral plantar fasciitis. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29540 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. You billed one line item of this code with the LT modifier and one line item of this 
code with the RT modifier instead of billing one line item with the bilateral modifier as is required. Based on 
this information, we decided that Medicare rules for coverage of procedure code 29540 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 29540 billed for date of service 
May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81479, 88341, 88342, 88360, and 88381 for 
date of service April 13, 2023. 
 
You asked the Plan to pay for procedure codes 81479, 88341, 88342, 88360, and 88381. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable 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 codes 81479, 88341 88342, 88360, and 88381 are not supported in the medical record. 
Specifically, the medical records submitted indicate that these services were performed on a different date of 
service. The codes cannot be verified as billed. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 81479, 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 81479, 88341, 88342, 88360, and 88381 for 
date of service April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service February 27, 2023, to 
March 5, 2023. 
 
You asked the Plan to pay for code 99233. You say that the medical records support the code billed. The Plan 
denied your request. The Plan says code 99233 is not supported by the medical record. The documentation 
supports a moderate level of medical decision making, so this was down-coded to 99232. 
 
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 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, 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, 50 minutes must be met or exceeded. 
 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 code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found this case pertains to a 59-year-old male with a past 
medical history significant for interstitial lung disease, chronic obstructive pulmonary disease (COPD), and 
diabetes who was admitted for a COPD exacerbation. At issue is coding accuracy as to high-level versus 
moderate-level medical decision-making. The documentation provided supports moderate decision-making 
rather than high-level decision making. As a result, the down-coding of code 99233 to code 99232 is justified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service February 27, 2023, to March 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81001 billed for date of service April 2, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 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 81001 is not supported in the medical record. The documentation provided does not 
include lab results to show that the services were rendered by the billing provider. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 81001 billed for date of service April 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent limb compression device. 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that the documentation 
demonstrates significant lymphedema and ongoing symptoms for this enrollee. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 The file shows that the enrollee has active and chronic non-obstructive bilateral lower extremity deep vein 
thrombosis. The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with 
venous stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve intermittent limb 
compression device.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 67966 rendered on May 22, 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) 67966 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 67966 is "Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full 
thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; 
over one-fourth of lid margin." 
 
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 preoperative clinic note, 
assessment, plan, operative note with service performed on May 22, 2023, and pathology report of eyelid lesion 
specimen submitted was most pertinent and reviewed in detail. Consent and operative note of procedure 
indicated a full thickness excision biopsy of left lower lid lesion.  CPT code 67966 is excision and repair of 
eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin 
graft or pedicle flap with adjacent tissue transfer or rearrangement more than one fourth of eyelid margin.  The 
consent and "Procedure performed" line of the the operative note was not clear that a repair of the eyelid 
margin was also performed.  The body of the operative note details did describe that a full-thickness repair of 
the eyelid involving the lid margin, muscle, and tarsus was documented. The length of the eyelid margin defect 
after the excisional biopsy was not documented in the operative note but based on the preoperative external 
pictures of the eyelid lesion and dimensions of the specimen submitted on the pathology report, it was at least 
one fourth of the eyelid margin. 
 
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 67966 rendered on May 22, 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: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel surgery (64721). 
 
You asked the Plan to pre-approve carpal tunnel surgery. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 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 carpal tunnel surgery. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative-care measures is not evident. There are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of carpal tunnel surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve carpal tunnel surgery (64721).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291, 99233, and 99239 for date of service 
February 21, 2023, to March 7, 2023. 
 
You asked the Plan to pay for procedure codes 99291, 99233, and 99239. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the codes at issue 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
The CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation care, per day, 
for the evaluation and management of a patient, 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, 50 minutes must be met or exceeded. 
 
The CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We find that CPT codes 99291, 99233, and 99239 are not supported in the medical record. Specifically, the 
codes definition are time-based, and the records submitted for review do not document the total time spent 
providing the services described by these codes. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 99291, 99233, and 99239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99291, 99233, and 99239 for date of service February 21, 2023, to 
March 7, 2023.