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

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair, captains chair, 
patient weight capacity up to and including 300 pounds (K0823), U1 sealed lead acid battery (E2365), and 
detachable armrest (E0973). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you have arthritis in 
bilateral arms, hands, and knees, and you are unable to walk. The Plan denied your request. The Plan says you 
do not meet Medicare criteria for a power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found you have impaired ambulation. The record does not address your capacity to use 
a scooter. Per L33789, the record does not indicate that you require a power wheelchair to manage MRADLs. 
 
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 durable medical equipment (DME) have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power wheelchair, captains chair, patient 
weight capacity up to and including 300 pounds (K0823), U1 sealed lead acid battery (E2365), and detachable 
armrest (E0973).
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 enrollee's 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 a COVID 19 infection. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 23, 2023, billed with 
codes 81479, 81401, 81227, 81225, 81226, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 
81105. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 23, 2023, billed with codes 81479, 81401, 81227, 81225, 81226, 81231, 81232, 81240, 81241, 81291, 
81306, 81328, 81335, and 81105.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 25, 2023, billed with 
evaluation and management (EM) code 99214-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care 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 99214-25 is office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter. 
 We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level, so code 99214-
25 is not supported. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 25, 2023, billed with evaluation and 
management (EM) code 99214-25.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation. 
 
You asked the Plan to pre-approve neuropsychological testing evaluation. You say that neuropsychological 
testing evaluation is medically necessary. The Plan denied your request. The Plan says the clinical 
documentation provided and reviewed does not indicate any cognitive impairment noted within the medical 
records. There is also no documentation provided showing a neurobehavioral exam showing that the member 
has any severity of symptoms that would warrant this time of diagnostic treatment. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is covered when the 
criteria listed in the Medicare rules section of this decision 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 neuropsychological testing evaluation. 
Our reviewer says that the requested neuropsychological testing evaluation is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee with a diagnoses including 
anxiety disorder and social phobia. The most recent documentation indicates the enrollee has "no impairment" 
regarding cognition. There is no indication that the enrollee has had any problems or decrease in cognition or 
function. There are no abnormal screening tests such as a MMSE or MOCA. There is no clear documentation 
available for review that would indicate a medical reason for formal neuropsychiatric testing. There is no 
documentation that indicates unexplained cognitive impairment or symptoms consistent with active mental 
health disorder. Neuropsychological testing is considered medically necessary when there are deficits on 
standard mental status testing or clinical interview, and a neuropsychological assessment is needed to establish 
the presence of abnormalities or distinguish them from other disease processes. Psychological testing is noted 
to typically require from 4-6 hours to perform, including administration, scoring and interpretation. Supporting 
documentation in the medical record must be present to justify greater than 8 hours per patient per evaluation. 
If the testing time exceeds 8 hours, medical necessity for the extended time should be documented in the 
medical record. In this case, the documentation available for review does not support medical necessity for the 
requested 32 hours of neuropsychological testing that has been requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing evaluation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve neuropsychological testing evaluation.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75710 and 75774 rendered on April 10, 
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 records do not support the services 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 the denied codes is: 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
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 provided records in this case 
do not support that CPT 75710 (Angiography, extremity, unilateral, radiological supervision and interpretation) 
or CPT 75774 (Angiography, selective, each additional vessel studied after basic examination, radiological 
supervision and interpretation) as a separate and distinct procedure from CPT 37244 (occlusion of arterial or 
venous hemorrhage with radiological supervision and interpretation, roadmapping, and imaging guidance). The 
provided records document one interventional angiographic procedure on April 10, 2023, of multiple arteries 
and arterial branches with embolizations.  
 
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 75710 and 75774 rendered on April 10, 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 the services are medically necessary for the 
enrollee's complex medical needs. The Plan denied your request. The Plan says ongoing skilled care can be 
provided in an alternative setting.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Ottobock Taleo K3 foot and Ottobock C-Leg 4 knee (L5828, 
L5845, L5848, L5856, L5999, L5981). 
 
You asked the Plan to pre-approve Ottobock Taleo K3 foot and Ottobock C-Leg 4 knee. 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 lower limb prostheses 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 Ottobock Taleo K3 foot and Ottobock 
C-Leg 4 knee. Our reviewer says that the services are medically necessary. Our physician reviewer found not only does the medical recordgo above and beyond in satisfying Medicare policy by demonstrating this enrollee 
has K3 functional level potential and has specific needs for the requested components, but the Plan also 
attempts to create a more restrictive policy for defining K3 function than Medicare policy would allow. 
Therefore, the requested microprocessor knee (L5828, L5845, L5848, L5856), cover (L5999), and foot (L5981) 
are 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 Ottobock Taleo K3 foot and Ottobock C-Leg 4 knee have been met. Therefore, 
we decided that the Plan has to pre-approve Ottobock Taleo K3 foot and Ottobock C-Leg 4 knee (L5828, 
L5845, L5848, L5856, L5999, L5981).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 27, 2023, to 
February 24, 2023. 
 You asked the Plan to pay for the home health services. You say that the bill type you used was correct. The 
Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from January 27, 
2023, to February 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87604, 87651, 87653, 87798) provided 
on September 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot e paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87604, 87651, 87653, & 87798 are not supported in the medical record. 
Specifically, multiple unbundled codes were submitted for a single panel. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (87481, 87604, 87651, 87653, 87798) provided on September 8, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain.  
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee meets all clinical criteria to approve 
the PET scan. You also say the PET scan is necessary to differentiate between FTD and AD. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the records provided for review 
suggested that the enrollee had previously been diagnosed with AD. There was no indication that the enrollee 
otherwise met diagnostic criteria for FTD or that they met diagnostic criteria for both AD and FTD 
simultaneously. In such a setting, the requested study would not meet the base requirement of the NCD for coverage 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4222 billed for date of service March 28, 2023.  
 You asked the Plan to pay for code A4222. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for code A4222 is 0. The MAI value for this code is 3. You billed 1 unit of this code, 
exceeding the MUE. You did not provide all the required evidence showing that the excess units were actually 
provided, were correctly coded, and were medically necessary. Based on this information, we decided that 
Medicare rules for coverage of procedure code A4222 have not been met. Therefore, we decided that the Plan 
does not have to pay for code A4222 billed for date of service March 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 3, 2022, to 
August 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 3, 2022, to 
August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on March 2, 2023, billed with 
procedure codes R0070, 99204-25, 74230, 74240, 72040, 70100, 71045, and 70310. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. As such, this is a non-covered service. Therefore, 
we decided that the Plan does not have to pay for radiological services provided on March 2, 2023, billed with 
procedure codes R0070, 99204-25, 74230, 74240, 72040, 70100, 71045, and 70310.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chest x-ray to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a chest x-ray to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a chest x-ray to be provided by an out-of-network (OON) provider.