Persius/hicric huggingface dataset:
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 are suffering by being in bed for too much time 
and 3 hours of rehab per day is clearly needed for you to recover, instead of 1 hour per day in another facility. 
The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are 
requesting do 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 lumbar spine surgery. Medical problems are stable. 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 pre-approve a group 3 standard power wheelchair with multiple 
power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and 
accessories (E0954, E1007, E1012, E2311, E2313, E2361, E2377, E2603). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee was 
wrongfully denied based on Medicare's LCD and should have been approved to help her quality of life and 
complete activities of daily living in an independent/timely manner. The Plan denied your request. The Plan 
says the enrollee does not have medical need for multiple power options included with a group 3 power 
wheelchair. The Plan also says the electronic connection, expandable controller harness, and expandable 
controller cannot be covered as it is not medically necessary to control the three requested power options 
through the joystick (drive interface). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is a chronic wheelchair user following a past stroke. She 
lives alone. She has intact skin and does not use a catheter. Per L33789, the enrollee does not have high risk for 
skin breakdown, use a catheter intermittently, have spasticity or require an alternative means of managing 
power drive. Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and accessories (E0954, 
E1007, E1012, E2311, E2313, E2361, E2377, E2603).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical traction device. 
 
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 a cervical traction device is 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records indicate that the enrollee has 
shoulder pain. No neck pathology is identified. There is no documented evidence that safe use has been 
demonstrated. The criteria for coverage are not met and the cervical traction device is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cervical traction device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services billed with procedure code 
49421 provided on April 26, 2023. 
 
You asked the Plan to pay for procedure code 49421. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 49421. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for 
procedure code 49421 have not been met. Therefore, we decided that the Plan does not have to pay for the 
assistant surgeon services billed with procedure code 49421 provided on April 26, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary The Plan denied 
your request. The Plan says the criteria for SNF care has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require daily skilled nursing or therapy services. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 11, 2023, billed with 
procedure 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 documentation does not support the billed code. 
 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 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that in this case evaluation and 
management service performed was directly related to the procedure performed, as the medical record 
describes that the patient presented with pain, which was evaluated, and an injection was given.  When a 
significant and separately identifiable EM and a procedure are both performed, the documentation of the 
encounter must clearly reflect two separate services with no overlap in work between the EM and the 
procedure. The documentation must explain what work was associated with the EM and separately explain 
what work was associated with the procedure, with a clear distinction that there was no overlap between the 
two. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 11, 2023, billed with procedure code 
99214-25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93229) provided on October 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 93229 is "External mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified health care professional". 
 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 use of code 93229 is 
not supported by the records provided. Our reviewer found that the medical records provided did not include a 
physician order for the external mobile cardiovascular telemetry, therefore this procedure cannot be verified. 
 
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 the services (93229) provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 1, 2023, billed with 
procedure code 99214. 
 
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 two of the billed diagnosis codes cannot be 
reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that Z11.3 has an Excludes1 note in relation to Z31.69. This means that the two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on June 1, 2023, billed with procedure code 99214.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy and physician 
attendance and supervision (G0277, 99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to 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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided 
documentation describes the enrollee as failing standard wound therapy, the same documentation also describes 
the wound as improving due to offloading, which is contradictory. Also, the enrollee has chronic foot ischemia, 
however, standard treatments such as cessation of smoking, dietary changes were not mentioned as having been 
fully exhausted, and there was not acute ischemia vs chronic as required. Therefore, the LCD criteria for 
hyperbaric oxygen therapy is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy and physician attendance 
and supervision (G0277, 99183).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the long term acute care hospital services provided on 
January 20, 2023, to May 15, 2023. 
 
You asked the Plan to pay for the long term acute care hospital services. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the long term acute care 
hospital services provided on January 20, 2023, to May 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 30, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not agree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for one-way trip ambulance services. 
 
You have been asked to pay a $200 copayment for ambulance services. This item/service falls within the one-
way trip ambulance services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
services provided on May 30, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services billed with codes 97530, 97112, 97110, 
and 97010 provided on June 21, 2023. 
 
You asked the Plan to pay for the therapy services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the provider was not credentialed to provide the rendered services. 
 
The Plan must follow Medicare rules. Medicare rules say that therapy services are payable when the treatment 
plan/plan of care is certified by a physician or NPP. 
 
We looked at the file and Medicare rules. Review of the file shows that the provider was not credentialed as a 
physical therapist until after this date of service. This means the services are not payable as billed. In addition, 
procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that procedure 
code 97010 is not separately payable. 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 pay for the 
therapy services billed with codes 97530, 97112, 97110, and 97010 provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0295) mattress, 
innerspring (E0271) bedside rails (E0305) and gel or gel-like pressure pad for mattress (E0185). 
 
You asked the Plan to pre-approve the hospital bed and accessories. You say that you do not understand why 
the bed is denied. The enrollee is more protected when using a hospital bed as the enrollee has had many falls 
in the past. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a semi-
electric hospital bed and a gel mattress overlay. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed and accessories. 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 noted to have Alzheimers Disease and impaired mobility. 
The enrollee requires the assistance of a walker when ambulating and is noted to be at risk for falling. The 
enrollee may require supervision and assistance for fall prevention and safety measures. However, there is 
insufficient documentation regarding the enrollees level of bed mobility and there is no indication that the 
enrollee is unable to reposition themself while in bed. There is no history of skin breakdown or pressure 
wounds and no indication that the enrollees bed requires elevation above 30 degrees. Therefore, the requested 
semi-electric hospital bed and gel mattress overlay 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 the hospital bed and accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a semi-electric hospital bed (E0295) mattress, innerspring (E0271) 
bedside rails (E0305) and gel or gel-like pressure pad for mattress (E0185).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair (PWC) with 
single power option, sling/solid seat/back, patient weight 301 to 450 pounds (K0858) and additional items and 
accessories (codes E1028, E2323, E1002, E2606, E0955, E1028, E1012, E2311, E2363 x2). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the enrollee did not get 
a wheelchair in February 2023, so if one was approved it was not billed for. You also say that an addendum 
was included that described why the enrollee cannot use the manual wheelchair from 2021. The Plan denied 
your request. The Plan says  this request is denied because it is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation available for review does not support that the 
enrollee requires a power mobility device to accomplish mobility related self-care tasks in the home. There is 
no indication they are unable to use an alternative assistive device. Furthermore, there is no documentation in 
the preceding 6-months of a face-to-face evaluation with the enrollee's medical provider or that he has an 
appropriate diagnosis for a group-3 PWC. The requested PWC is 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 the durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair (PWC) with single power option, sling/solid seat/back, patient weight 301 to 450 pounds (K0858) and additional items and 
accessories (codes E1028, E2323, E1002, E2606, E0955, E1028, E1012, E2311, E2363 x2).