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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that the Intracept procedure is medically necessary and 
supported by strong science. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
this procedure. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found magnetic resonance imaging (MRI) shows multiple levels of facet degenerative joint disorder 
and the cause of back pain is unclear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 continued physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy 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. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee is able to walk more than 350 feet and has four-to-five out 
of five strength in her lower extremities. She is able to perform a home exercise program and is functional. She 
is receiving repetitive strength training, which is not a skilled service. The enrollee does not require continued 
skilled therapy and the 12 additional visits are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 continued physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an echocardiography transesophageal (TEE) for 
guidance of a transcatheter intracardiac or great vessel (93355) and a transcatheter mitral valve repair 
percutaneous approach including transseptal puncture when performed; initial prosthesis (33418). 
 
You asked the Plan to pre-approve a MitraClip procedure. You say that you are requesting reconsideration 
because the enrollees initial echocardiogram that was submitted did not have all of the required 
documentation. You are submitting an amended report. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for approval of the requested procedure. 
 
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 MitraClip procedure. 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 significant aortic and mitral valve regurgitation and left ventricular 
dysfunction, for which the physician has requested authorization for transcatheter mitral valve repair (TMVR). 
The records do not address whether peri-procedural anti-coagulation and chronic anti-platelet therapy are 
practicable in light of the chronic thrombocytopenia. The documentation is inadequate to confirm fulfillment of 
published CMS guidelines for TMVR. As a result, at this time TMVR would not be considered medically 
reasonable and necessary in this enrollees 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 a MitraClip procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an echocardiography transesophageal (TEE) for guidance of a transcatheter 
intracardiac or great vessel (93355) and a transcatheter mitral valve repair percutaneous approach including 
transseptal puncture when performed; initial prosthesis (33418).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says admission to an IRF is not medically necessary 
at this time. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on June 15, 
2022. 
 
You asked the Plan to pay for the subsequent hospital care. The Plan denied your request. The Plan says there 
is insufficient documentation to corroborate the services so it can be confirmed that Medicare coverage has 
been met. 
 
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 care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit.  
 
We 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 subsequent hospital care. Our reviewer says that this code 
is not supported. Our reviewer found the enrollee is a 79-year-old who was treated in the hospital on June 15, 
2022. The enrollee had aphasia and right-sided weakness. Our reviewer found that the note from that date 
described the enrollee feeling claustrophobic leading to postponing the magnetic resonance imaging, with 
mention of hemiplegia persistent, a brief, focused history. It also included a physical exam that was general but 
not detailed. Our physician reviewer found that the enrollee was stable. Code, 99233, was submitted. Our 
physician reviewer also found that the provided documentation did not clearly show a detailed history or 
physical, nor was there evidence from the documentation of medical decision-making of high complexity to 
support this code for this date. 
 
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 subsequent hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care (99233) provided on June 15, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285 and 93010 billed for date of service 
August 19, 2022. 
 You asked the Plan to pay for the billed services. You say that the enrollee was seen for a medically necessary 
procedure. The Plan denied your request. The Plan says the underlying condition should be sequenced first. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes 99285 and 93010 were billed with primary diagnosis code D63.1, erythropoietin 
resistant anemia. This diagnosis has a code first notation, indication that it is not permitted to be used as a 
primary diagnosis code. 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 
99285 and 93010 billed for date of service August 19, 2022.
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 to be discharged to the IRF. The Plan 
denied your request. The Plan says your needs can be met at a lower level of care. 
 
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 your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service September 
19, 2022. 
 You asked the Plan to pay for procedure code 99152. The Plan denied your request. The Plan says payment for 
code 99152 is bundled into payment for code 45378. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99152 
is a column II code to column I code 45378. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99152 billed for date of 
service September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 11, 2021. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on June 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with a single power option 
and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with a single power option. You say that you 
want to appeal this denial. The Plan denied your request. The Plan says a Group 3 power wheelchair with 
single power option is not medically necessary. The Plan also says that the related accessories are not 
medically necessary either. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered when certain 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 a Group 3 power wheelchair with a 
single power option. Our reviewer says that a Group 3 power wheelchair with a single power option is not 
medically necessary. Our physician reviewer found the provided documentation does not indicate the enrollee 
uses a catheter, is at high risk for skin breakdown, requires alternate controls and has spasticity. The reviewer 
found that the enrollee's condition does not fulfill Medicare criteria for a Group 3 power wheelchair with single 
power option. Therefore, the reviewer found that a Group 3 power wheelchair with single power option 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 a Group 3 power wheelchair with a single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with a single 
power option and accessories.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal simplicity interspinous-interlaminar fusion 
device (22612, 22840). 
 
You asked the Plan to pre-approve a Minuteman device. You say that you are requesting reconsideration 
because the enrollee has tried epidural injections, radio frequency ablation and physical therapy that has not 
provided any relief. The Plan denied your request. The Plan says this service is considered experimental and 
investigational as it is not identified as widely used and generally accepted for the proposed use as reported in 
nationally recognized peer-reviewed medical literature. 
 
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 Minuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman device is experimental and investigational. There is more research 
needed. The Medicare criteria for reasonable and necessary are not met because use of this device as a stand-
alone procedure has not been shown to be safe and effective in long term studies. 
 
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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal simplicity interspinous-interlaminar fusion device (22612, 22840).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for April 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99223 is not supported by the medical records. 
 
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 99223 is initial 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, 75 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 these services. Our reviewer says that procedure code 99223 is not supported by the medical records. Our reviewer found the enrollee presented to the emergency 
department with syncope. He was evaluated by pain management for increased right leg pain. The records do 
not support that a comprehensive history, comprehensive exam, and medical decision making of high 
complexity were performed for April 4, 2022. 
 
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 99223 billed for April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the K3 microprocessor knee and foot components. 
 
You asked the Plan to pre-approve the K3 microprocessor knee and foot components. You say that the items 
are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee or foot. 
This information must be retained in the treating practitioner's or prosthetist's files. 
 
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 K3 microprocessor knee and foot 
components. Our reviewer says that the member does not need these items. Our physician reviewer found the 
documentation does not support that the member is able to ambulate at a K3-functional level.  There is no clear 
documentation to support the member requires a microprocessor knee or upgraded components. 
 
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 K3 microprocessor knee and foot components have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the K3 microprocessor knee and foot components.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the enrollee urgently needs this device 
and procedure due to his worsening heart failure. The Plan denied your request. The Plan says the 
CardioMEMS device has been determined to be of uncertain value in the most recent 2022 ACC/AHA 
guidelines and carries a risk of significant complications including death and severe pulmonary artery injury. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of enrollees with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was implanted, 
reflecting an enrollee population with preserved ejection fraction and was somewhat limited in scope. 
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in enrollee management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollee's 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289, C2624).