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

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 22, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 22, 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical management of a small bowel obstruction. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does 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 
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. 
 
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 pay for code A4566 billed for date of service May 15, 2023. 
 
You asked the Plan to pay for code A4566. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 A4566 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A4566 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of code A4566 have not been met. Therefore, we decided that the Plan does not have to pay 
for code A4566 billed for date of service May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595, E0731) provided on 
March 31, 2023. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that these items were medically 
necessary. 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 to support the supplies provided in this case. An itemized 
proof of delivery was not provided. 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 
electrical stimulator supplies (A4595, E0731) provided on March 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service March 24, 
2023. 
  You asked the Plan to pay for procedure code 20930. The Plan denied your request. The Plan says procedure 
code 20930 is considered bundled and not separately payable.  
 
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 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J2250 and 99152 billed for date of service 
May 1, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records document the services. The 
Plan denied your request. The Plan says the billed services 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 J2250 is injection, midazolam hydrochloride, per 1 mg. 
The definition of code 99152 is moderate sedation services provided by the same physician or other qualified 
health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring 
the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status 
 
We find that CPT codes J2250 and 99152 are not supported in the medical record. The claim billed 4 units of 
code J2250. The medical records show that only 2 milligrams (2 units) were provided. The medical records do 
not show that the moderate sedation services required the presence of an independent trained observer. 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 codes J2250 and 99152 billed for date 
of service May 1, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the 
enrollee's current condition and functional deficits, as well as their multiple comorbidities. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record complies with the various documentation requirements for IRF admission. The 
enrollee's condition is in fact complex, and there is every reason to expect that they will participate in and 
benefit from services to include at minimum physical, speech, respiratory and occupational therapy, physician 
oversight, polypharmacy, and case manager coordination of any additional services that might be needed to 
make a sustainable return home as well as avoid preventable readmissions to the acute hospital. Therefore, the 
requested inpatient rehab facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 pay for the inpatient behavioral health services provided on March 
25, 2023. 
 You asked the Plan to pay for the inpatient behavioral health services. You say that the inpatient level of care 
was medically necessary for the enrollee. The Plan denied your request. The Plan says the inpatient level of 
care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 behavioral health services. Our 
reviewer says that the inpatient behavioral health services are not medically necessary. Our physician reviewer 
found the records provided it was not expected this enrollee would improve in a reasonable period of time as 
they did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not 
showing any behavioral issues. The enrollee was not showing any withdrawal symptoms. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient/detoxification level 
of care rather than a lower level of care as they did not have dangerousness to self or others, perceptual 
disturbance including delusions, auditory or visual hallucinations. Therefore, the reviewer found that the 
inpatient behavioral health services were 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 inpatient behavioral health services have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient behavioral health services provided on March 25, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service March 10, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test assesses the possibility of developing 
cancer. The Plan denied your request. The Plan says screening genetic testing is not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The records do not show that the enrollee has a history of cancer. The 
records do not show the testing was ordered for the treatment of a specific medical problem. The test at issue in 
this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening 
purposes. The panel testing was also not billed with a single code as required. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the panel testing billed for date of service March 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 51785 billed for February 26, 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 51785 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 51785 is needle electromyography studies (EMG) of anal 
or urethral sphincter, any technique. 
 
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 these services. Our reviewer says that procedure code 51785 
is not supported. Our reviewer found the submitted procedure report does not include documentation of needle 
electromyography (EMG) of the anal or urethral sphincter. The procedure is not found in the medical records.  
We looked at this coder's review, the file, and Medicare rules. 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 51785 billed for February 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostatic arterial embolization (PAE). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found PAE is considered experimental to treat 
benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term efficacy and 
safety. The most recent American Urological Association (AUA) guidelines do not recommend this procedure 
outside of a clinical trial setting due to the heterogeneity in the available literature and safety concerns 
regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, higher clinical failure rate compared with more traditional methods. The services are therefore not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prostatic arterial embolization (PAE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377), harness (E2313), legrest assembly 
(K0108), and alternative switchbox (K0108). 
 
You asked the Plan to pre-approve the electrical connection between the wheelchair controller and two or more 
motors, expandable controller, harness, legrest assembly, and alternative switchbox. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the enrollee has adequate upper body 
strength to control power options through the standard switches. 
 
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 electrical connection between the 
wheelchair controller and two or more motors, expandable controller, harness, legrest assembly, and alternative 
switchbox. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee has adequate upper body strength to control power 
options through the standard switches. 
 
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 electrical connection between the wheelchair controller and two or more 
motors, expandable controller, harness, legrest assembly, and alternative switchbox have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the electrical connection between the 
wheelchair controller and two or more motors (E2311), expandable controller (E2377), harness (E2313), 
legrest assembly (K0108), and alternative switchbox (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99291 rendered from March 16, 
2023, to March 20, 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 the information submitted does not support this level of 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99233: 
 
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 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the notes do not support either 
level of service. There is no documentation of time and the notes do not qualify for this level of complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99233 and 99291 rendered from March 16, 2023, to March 20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service March 6, 
2023. 
 
You asked the Plan to pay for procedure code 95937. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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. 
 
In this case, the CPT Code Manual definition of code 95937 is: Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 95937. Our reviewer says that procedure 
code 95937 does not meet criteria for payment. Our reviewer found that the procedure report describes Train of Four (TOF) testing, which would not be reported with neuromuscular junction testing procedure code. CPT 
95937 should not be used for TOF Monitoring. No procedure code exists for TOF testing, as this procedure is 
included in the primary procedure code for intraoperative neuromonitoring service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95937 billed for date of service March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81551) provided on December 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing 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 (81551) provided on December 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right knee arthroscopy with synovectomy and 
chondroplasty. 
 
You asked the Plan to pre-approve a right knee arthroscopy. You say that the enrollee has done physical 
therapy without any improvement. The Plan denied your request. The Plan says this procedure does not meet 
guideline requirements. 
 
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 right knee arthroscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. The provided diagnostic imaging 
studies did not corroborate significant pathology. No compelling rationale is 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 a right knee arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a right knee arthroscopy with synovectomy and chondroplasty.