Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 5, 2022, to 
October 13, 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 
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 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 secondary diagnosis code J69.0, described as 
Pneumonitis due to inhalation of food and vomit. 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 reviewer says that documentation does not 
support the billed code. Our physician reviewer found the enrollee is a 78-year-old female who presented for 
dizziness and tachycardia with palpitations diagnosed with atrial fibrillation. Lung exam was without 
rales/wheezes. She had normal respiratory effort. There was no report of vomiting or aspiration from other 
cause. Pneumonitis due to aspiration (J69.0) was not evidenced in the provided documentation.   
 
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 inpatient hospital services provided on October 5, 2022, to October 13, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
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 rehabilitation due to being super 
week and needing extra help from being on a ventilator. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99215) provided on November 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99215 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 40-54 minutes of 
total time is spent on the date of the encounter". 
 
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 99215 is not supported by the records provided. Our reviewer found that the medical records submitted do not support a 
high level of medical decision making or total time required of the code 99215. 
 
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 (99215) provided on November 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the cervical spine. 
 
You asked the Plan to pre-approve the MRI. You say that you need to know what you are dealing with before 
doing physical therapy. The Plan denied your request. The Plan says the request for an MRI is not medically 
necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found you have chronic neck pain. The 
record provided does not document the presence of red flag signs or symptoms or an abnormal neurologic 
examination. The record does not indicate that a trial of conservative therapy has been tried and failed. The 
elements of the coverage criteria are not satisfied. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the cervical spine.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the enrollee is receiving adequate and necessary intensive rehabilitation in the 
inpatient rehabilitation facility (IRF). The Plan states all the services the enrollee needs are offered at the IRF. 
The Plan states transfer to a SNF for inpatient skilled rehabilitation services is not medically necessary.  
 
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 skilled nursing or therapy services on a daily basis. 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skin substitute (Epifix) (Q4186) and application 
(15271 x5). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the skin substitute (Epifix) is considered experimental and investigational. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation in the provided clinical notes indicating that the enrollee has failed 
soft padding, soft elbow supports and/or ACE wraps for olecranon bursitis. Also, the enrollee has been using 
Tubi-grips for compression with no sustained relief. Additionally, there is no documentation that he has tried non-steroidal anti-inflammatory drugs (NSAIDs) or potential injections or sclerosing agents. EpiFix is not 
Food and Drug Administration (FDA) approved for persistent drainage from olecranon bursitis or surgical 
wounds. There is no long-term data documenting that placement of a skin substitute will stop the continued 
drainage and allow healing in patients with chronic draining olecranon bursitis. Persistent drainage from a prior 
drainage site is not a covered indication for skin substitute. The review has determined that the items/services 
at issue in this case are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skin substitute (Epifix) (Q4186) and application (15271 x5).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
June 20, 2023, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the enrollee's records do not show that the enrollee requires 
inpatient active psychiatric treatment, at the inpatient level. The Plan states the enrollee's providers say that the 
enrollee is at their psychiatric baseline. The Plan states that the continued stay at the psychiatric inpatient hospitalization level of care for this admission is not medically necessary beginning June 20, 2023. The Plan 
states the service the enrollee needs can be provided safely in other settings. The Plan states examples of these 
may include residential treatment, partial hospital program, or outpatient services. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found the enrollee had no acute psychiatric issues that would require continued inpatient 
care beyond June 2, 2023. The enrollee has chronic symptoms. The available medical records do not support 
that continued inpatient care will change these symptoms or the enrollee's current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of inpatient mental health care from June 20, 2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0444 and G2211 billed for date of service 
February 3, 2023. 
 
You asked the Plan to pay for procedure codes G0444 and G2211. The Plan denied your request. The Plan says 
payment for codes G0444 and G2211 is bundled. 
 
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 G0444 
is a column II code to column I code 99213. 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. 
 
 
We also find that procedure code G2211 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code G2211 is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code G2211 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes G0444 and G2211 billed for date of service February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87640, 87652, 87798) provided on January 9, 
2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87640, 87652, & 87798 are not supported in the medical record. Specifically, 
individual lab results were not provided for the billed codes. Multiple unbundled codes were submitted for a 
single pane.. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (87640, 87652, 87798) 
provided on January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the patient has been revascularized 
and her condition of osteomyelitis qualifies her for hyperbaric oxygen. The Plan denied your request. The Plan 
says the patient's medical records do not show failure to respond to wound care for 30 days after the vascular 
correction. 
 
The Plan follows Medicare rules. Medicare rules say that in order to qualify for hyperbaric oxygen, the patient's 
records must document a failure to respond to wound care for 30 days. 
 
 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 hyperbaric oxygen therapy. Our 
reviewer says that the patient does not meet coverage criteria for hyperbaric oxygen therapy. Our physician 
reviewer found the records do not show failure of standard wound care as there is no documentation of failure 
to respond to wound care 30 days after the vascular correction of identified vascular problems in the affected 
limb and completion of adequate treatment of active infection. As a result, the requested hyperbaric oxygen 
therapy 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 hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (0266T and C1825). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the Barostim Neo device is considered unproven and 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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Barostim Neo device (0266T and C1825).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (93005, 74177, 93041) provided on 
January 5, 2023. 
 
You asked the Plan to pay for the outpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 93005, 74177 & 93041 is not supported in the medical record. Specifically, code 74177 
has a status indicator of Q3. Codes 93005 and 93041 have a status indicator of Q1. These codes were billed on 
the same date of service as code 99285 which has a status indicator of "V". Based on this information, we 
decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided 
that the Plan does not have to pay for outpatient services (93005, 74177, 93041) provided on January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87631, 94761, 99072) provided on August 10, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing (87631) 
have not been met. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. We also find that procedure code 94761 has a status indicator 
T on the Physician Feed Schedule. This means that procedure code 94761 is not separately payable as there are 
other payable services billed for this date of service. 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 (87631, 94761, 99072) provided on August 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  multiple venous procedures with sedation (37238, 
75820, 99152, 37239). 
 
You asked the Plan to pre-approve the services. You say that this is affecting daily activities and has severe 
pain.  The Plan denied your request. The Plan says the services are not medically 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 the services. Our physician reviewer 
found at issue is the medical appropriateness and necessity of venous angiography and stent placement in this 
enrollee's management. The documentation does not meet guideline criteria for use of this therapy: 
Documentation shows no evidence of thrombus or venous occlusion. In summary, there is insufficient 
documentation to support the medical necessity for the requested venous angiography and stent placement 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 the services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve  multiple venous procedures with sedation (37238, 
75820, 99152, 37239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis 
codes cannot be billed together. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes G47.33 and 
E66.2. Diagnosis code G47.33 has an Excludes1 note and cannot be billed with diagnosis code E66.2. As such, 
the claim is not payable as billed. 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 
provided on December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulation leads provided on December 
30, 2022.  
 
You asked the Plan to pay for the Cala Trio leads. You say that the services are beneficial and should be 
covered.  The Plan denied your request. The Plan says this is not covered by Medicare.  
 
The Plan follows Medicare rules. Medicare rules say that payment cannot be made for electrical stimulation 
when used to treatment movement disorders. 
 
 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 Cala Trio leads. Our reviewer says that 
the items provided are not shown to meet Medicare coverage criteria.  Our physician reviewer found when 
electric nerve stimulation is employed to treat motor function disorders, no reimbursement may be made for the 
stimulator or for the services related to its implantation since this treatment cannot be considered reasonable 
and necessary. The patient has a motor function disorder with tremor, and the medically necessary criteria for 
this device have not been 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 the Cala Trio leads have not been met. Therefore, we decided that the Plan does 
not have to pay for the Cala Trio nerve stimulation leads provided on December 30, 2022.