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

 
We decided that the Plan does not have to pay for procedure code 99309 is not supported. 
 
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 99309 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 99309 is subsequent nursing facility 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 moderate 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 has 
developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the 
bedside and on the patient's facility 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 these services. Our reviewer says that procedure code 99309 
is not supported. Our reviewer found the enrollee received care in a rehabilitation center. The records do not 
support a detailed examination or medical decision making of moderate complexity were performed. Code 
99309 is therefore not supported. 
 
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 99309 is not supported.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from April 25, 2023, to April 27, 
2023. 
 
You asked the Plan to pay for the medical services. You say that hospice was terminated, so this claim should 
be reprocessed. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 5, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
from April 25, 2023, to April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the enrollee's left upper limb strength and function are adequate for the 
enrollee to be able to control the power options using their own switches which are included in the allowance 
of these power options. 
 
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 an electronic connection. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee's left upper limb strength and function are adequate for the enrollee to be able to 
control the power options using their own switches which are included in the allowance of these power options.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that without access to respiratory support 
via non-invasive ventilator, the enrollee is at risk for de-compensation, exacerbation, and hospitalization. The 
Plan denied your request. The Plan says a home ventilator is not medically necessary for this patient because 
their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator system. Our reviewer 
says that a home ventilator is not medically necessary. Our physician reviewer found that the enrollee has a 
history of COPD and was recently hospitalized with pulmonary edema and pleural effusions due to 
exacerbation of diastolic heart failure. Although, past pulmonary function tests support moderate COPD, there 
is no diagnosis of thoracic restrictive disease or neuromuscular disease. However, the enrollee has improved 
with a BiPAP and may benefit from a BiPAP with AVAPS during sleep as an outpatient. Therefore, a home 
ventilator 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 a home ventilator system. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection (E2311). 
 
You asked the Plan to pre-approve the electronic connection. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the enrollee's bilateral upper limb strength and function are adequate 
for the enrollee to be able to control the power options using their own switches which are included in the 
allowance of these power options. 
 
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 electronic connection. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has adequate strength to manage standard power drives. 
 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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection (E2311).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) coronary calcium scoring. 
 
You asked the Plan to pre-approve CT coronary calcium scoring. You say that your patient has been diagnosed 
with mixed Hyperlipidemia and has been being treated under your care. You say that the patient has failed 
Zetia and high dose statins and is unable to get low-density lipoprotein (LDL) under 50. The Plan denied your 
request. The Plan says according to Medicare rules calcium scoring reported in isolation is considered a 
screening service. This means this test cannot be used for calcium scoring alone. You must also have symptoms 
such as chest pain. The medical record does not show any symptoms of chest pain. 
 
The Plan follows Medicare rules. Medicare rules say that CT coronary calcium scoring 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 CT coronary calcium scoring. Our 
reviewer says that the requested CT coronary calcium scoring is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee would not benefit from the requested test. 
CT coronary calcium scoring has a class 2b recommendation for use in individual with moderate 10 year risk 
of suffering a cardiovascular event who need more evidence of long term benefit from starting statins. 
The enrollee is already on high dose statins. The guidelines from the professional societies recommend about 
50% reduction of baseline LDL in primary prevention. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT coronary calcium scoring have not been met. Therefore, we decided that the 
Plan does not have to pre-approve CT coronary calcium scoring.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 8, 2023, billed with 
procedure code 99213. 
 
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 billed code was not billed with the required 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, the Plan says code 99213 is within the global period of code 52601, but the 
documentation provided did not include proof of payment nor medical records for the primary procedure 
performed on February 20, 2023. . Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on May 8, 2023, billed with procedure code 99213.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services received from April 24, 2023, to May 
18, 2023. 
 
You asked the Plan to pay for the therapy services. You say that it is very difficult to find a new therapist that is 
accepting patients and accepts this insurance. The Plan denied your request. The Plan says the services received 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the therapy services received from April 
24, 2023, to May 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045-26 billed for date of service April 19, 
2023. 
 You asked the Plan to pay for procedure code 71045-26. You say that the enrollee had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 71045-26 is bundled into 
payment for code 32555-RT. 
 
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 
71045-26 is a column II code to column I code 32555-RT. This claim has not been billed with an appropriate 
modifier to bypass the edit. 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 71045-26 billed for date of service 
April 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on April 20, 2022, to 
April 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
coding is supported by the clinical indicators and treatment. The Plan denied your request. The Plan says the 
records did not clinically validate the diagnoses.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code N17.9, defined as acute kidney 
failure, unspecified; R63.4, defined as abnormal weight loss; and Z68.1, defined as body mass index of 19.9 or 
less. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our physician reviewer found that acute kidney injury is generally defined as an increase in 
serum creatinine or urine output for 6 to 12 hours after optimization of volume status and exclusion of 
obstruction. The provided records document the enrollee had a creatinine of 1.43 after optimization of fluid 
status with a baseline of 1.29 from October 19, 2021. This does not meet the criteria for acute kidney injury. 
The provided records also do not fully support diagnosis codes for abnormal weight loss or a body mass index 
of 19.9 or less, as objective measure of weight loss was not provided. Therefore, the documentation does not 
validate the diagnoses.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on April 20, 2022, to April 21, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) billed for 
dates of service January 1, 2023, to January 6, 2023. 
 
You asked the Plan to pay for code E0217. You say that this item is medically necessary based on medical 
literature. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that water circulating heat pads with pumps (code 
E0217) are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0217 have not been met. Therefore, we decided that the Plan does not have to pay for the 
water circulating heat pad with pump (E0217) billed for dates of service January 1, 2023, to January 6, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you want to continue with SNF and gain your 
strength and energy back to return to being independent. The Plan denied your request. The Plan says you do 
not require daily nursing care that must be provided in a skilled nursing facility. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care.
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 is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show rehabilitation needs are 
complex.  The Plan says that the services needed may be provided safely in 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 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.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service March 28, 2023, 
to April 26, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. 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 start of care date is January 30, 2023. The NOA was not received by the Plan until June 8, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service March 28, 2023, to April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV), group 1 standard, 
patient weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a POV. You say that you had a toe amputation. You have very bad 
neuropathy in both legs and the neuropathy in your hands would make the use of a manual wheelchair 
significantly debilitating, power would the better option. The Plan denied your request. The Plan says the 
request is not medically necessary because the records show you have the strength in your upper extremities to 
finish your MRADL's in the home with a manual wheelchair. 
 
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 POV. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack of clinical documentation indicating your level of mobility, function (toileting, 
dressing, bathing, etc.), and physical examination findings, specifically with regards to graded motor strength 
in the upper and lower extremities. It appears that you cannot use a cane or walker for assistance with mobility. 
You require assistance with ambulation. You can use the requested mobility device. However, it is not clear 
why you cannot propel a manual wheelchair for mobility and accomplishing your daily activities. Therefore, 
the group 1 power mobility device or power scooter 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 a POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV), group 1 standard, patient weight capacity up to and including 
300 pounds (K0800).