Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  testing services provided on May 18, 2023, billed with 
procedure code 38999. 
 
You asked the Plan to pay for  the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says additional information is needed. 
 
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 pay for the testing services provided. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 67-year-old male with polycythemia vera and myelofibrosis who is 
enrolled in a clinical trial to assess cord-blood derived T-regulatory cells. However, coverage for this code, is 
not supported as the enrollee needs to seek coverage from their original Medicare Administrative Contractor. 
Therefore, the code 38999 will be considered not medically necessary 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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for  testing services provided on May 18, 2023, billed with procedure code 38999.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinic services, identified by revenue code 0510, billed 
for dates of service July 13, 2023, to July 19, 2023. You asked the Plan to pay for the billed service. You say that the service occurred within 24 hours of the 
admission. The Plan denied your request. The Plan says the service is not separately reportable. 
 
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 looked at the file and the rules. The services billed with revenue code 0510 was provided within 3 days of 
an inpatient admission. The records do not show that the services at issue were unrelated to the inpatient 
admission. Based on this information, we decided that Medicare rules for coverage of the billed service have 
not been met. Therefore, we decided that the Plan does not have to pay for the clinic services, identified by 
revenue code 0510, billed for dates of service July 13, 2023, to July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair accessory, tray (E0950) and repair or 
nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a 
technician, labor component, per 15 minutes (K0739). 
 You asked the Plan to pre-approve the wheelchair accessories. You say that you delivered a power wheelchair 
with tray to the enrollee, but the tray did not work, and you started a separate order for the tray. Please review 
the attached documentation for medical necessity. The Plan denied your request. The Plan says the current 
wheelchair was purchased August 8, 2023.  Medicare does not replace or repair DME items that are still under 
warranty. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. This is covered under warranty. Therefore, we decided that 
the Plan does not have to pre-approve the wheelchair accessory, tray (E0950) and repair or nonroutine service 
for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor 
component, per 15 minutes (K0739).
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 needs aggressive rehabilitation to assist 
with regaining their strength and function in order to return to their workout regimen in the future. 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees 
medical problems are stable. The enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 1, 
2023. 
 You asked the Plan to pay for the ED services. You say that you are not a Medicare provider, but your facility 
claim should be paid. The Plan denied your request. The Plan says Medicare payment cannot be made to this 
type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on May 1, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 110004 billed for date of service March 29, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the notes and photos support payment for 
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. 
 
In this case, the CPT Code Manual definition of code 11004 is debridement of skin, subcutaneous tissue, 
muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum. 
 
 We find that CPT code 11004 is not supported in the medical record. The records show that the enrollee was 
treated for a sacral wound. There is a more applicable code to describe the services provided. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 110004 billed for date of service March 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home health or hospice setting (G0299) and direct skilled nursing services of a licensed practical nurse 
(LPN) in the home health or hospice setting (G0300).  
You asked the Plan to pre-approve home health services. You say that you need a nurse in your home. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that you require additional skilled nursing services to provide treatment that is 
medically necessary. You do not require additional skilled nursing or rehab services to effectively provide 
treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain 
your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. The requested home health services are not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home health or 
hospice setting (G0299) and direct skilled nursing services of a licensed practical nurse (LPN) in the home 
health or hospice setting (G0300).
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the notes do not show that the enrollee's care 
specifically requires the involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show 
that the enrollee has complex care needs that require a coordinated team approach; the notes do not show that 
the enrollee must have an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve 
self-care functioning.  
 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 members nursing, medical, and rehabilitation needs does not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional 
status.  The enrollee can receive further services 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: 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 you need IRF services as you have decreased 
mobility, safety, speech and you need progressive care. The Plan denied your request. The Plan says you do not 
meet the requirements for an IRF admission.  
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. You do 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. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation program provided in an 
IRF. 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: 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 you had back surgery and have screws in your back. 
You say that you need rehab to recover. 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95937, G0453, and 95940 billed for March 
23, 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 the codes 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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95940 is continuous 
intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal 
attendance, each 15 minutes (List separately in addition to code for primary procedure). The definition of code 
G0453 is continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary 
procedure). 
 
We find that CPT codes 95937, 95940, and G0453 are not supported in the medical record. Specifically, the 
records show that Train of Four testing was performed and there is a more appropriate code than 95937. There 
is no documentation of the presence of a monitoring professional in the operating room to support code 95940. 
Code G0453 is an add-on code that was not billed with a required primary procedure code. 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 95937, G0453, and 95940 billed for March 23, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance (64454). 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that you are requesting reconsideration 
because the enrollee is experiencing severe pain that hinders activities of daily living. The Plan denied your 
request. The Plan says the request is not medically necessary because based on the medical literature this 
procedure is considered experimental or investigational and has not been proven to be beneficial for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular nerve blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of chronic right knee pain. The pain is rated 9/10 and is 
considered neuropathic in nature. Genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following, degenerative joint disease; osteoarthritis of the knee; as a treatment prior to 
knee replacement; as a treatment following knee replacement; or as a treatment for enrollees who are not 
candidates for knee replacement surgery. The review has determined that the requested right genicular nerve 
block is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance (64454).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CNSide Melanoma Profile provided on May 9, 2023. 
 
You asked the Plan to pay for the CNSide Melanoma Profile. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that this test must successfully complete a 
comprehensive TA by MolDX.  
 
We looked at the file and Medicare rules. We find that the the CNSide Melanoma Profile test has not been 
approved for coverage based on information in the DEX Diagnostic Exchange. Based on this information, we 
decided that Medicare rules for coverage of the CNSide Melanoma Profile have not been met. Therefore, we 
decided that the Plan does not have to pay for the CNSide Melanoma Profile provided on May 9, 2023.