Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET scan concurrently with a CT scan of the whole body. 
 
You asked the Plan to pre-approve PET/CT scan. You say that the enrollee has a risk of cancer, and a biopsy 
cannot be ordered. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET/CT scan. Our reviewer says that 
the request is medically necessary. Our physician reviewer found the enrollee has atrial fibrillation and is 
morbidly obese. Recent CT showed a 3.4 centimeter left adrenal mass with central calcifications. They also 
have enlarged retroperitoneal lymph nodes. The request for a PET/CT is reasonable since a malignant diagnosis 
is quite possible and biopsy would be associated with elevated risk. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a PET scan concurrently with a CT scan of the whole body.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve the electrical connection between the wheelchair controller and two or more 
motors, expandable controller, and harness. You say that the items are medically necessary. The Plan denied 
your request. The Plan says the items are 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 electrical connection between the 
wheelchair controller and two or more motors, expandable controller, and harness. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have adequate upper body strength to control power options through standard switched.  
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 electrical connection between the wheelchair controller and two or more 
motors, expandable controller, and harness have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the electrical connection between the wheelchair controller and two or more motors 
(E2311), expandable controller (E2377), and harness (E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee was hospitalized due to COPD. 
The enrollee has tried and failed BiPAP. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for approval of a ventilator. 
 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, sarcoidosis, 
obstructive sleep apnea, severe obesity, heart failure with reduced ejection fraction (HFrEF), and coronary 
artery disease. The enrollee was recently hospitalized with congestive heart failure and acute exacerbation of 
COPD. An arterial blood gas (ABG) on August 5, 2023, is partially illegible, but the partial pressure of carbon 
dioxide (PaCO2) is 46. There are no pulmonary function tests to assess the severity of the COPD. 
Polysomnography on December 12, 2022, showed moderate obstructive sleep apnea. Positive airway pressure 
(PAP) titration was unsuccessful with CPAP or BiPAP. There is no documentation of chronic carbon dioxide 
(CO2) retention with an ABG done while stable. If that is present, the enrollee may benefit from BiPAP with 
average volume assured pressure support (AVAPS) during sleep as an outpatient. The records do not show this 
has been tried as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0318 billed for date of service May 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that bundling the payment conflicts with the Plan's 
reimbursement policies.  The Plan denied your request. The Plan says that procedure code 99350 is included in 
code G0318. 
 
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 G0318 is prolonged home or residence evaluation and 
management service(s) beyond the total time for the primary service (when the primary service has been 
selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified 
healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99345, 
99350 for home or residence evaluation and management services). 
 
The claim shows that code G0318 was billed on the same date of service as code 99350. We find that CPT 
code G0318 is supported. The CPT Code Manual specifically states that G0318 is billed in addition to code 
99350. This add-on code and has been billed with an appropriate primary procedure code. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for procedure code G0318 billed for date of service May 8, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
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 will need 24-hour nursing for safety, 
patient/family education on disease processes, monitoring of vital signs, and medication administration. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements. 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam therapy (PBT) for recurring breast cancer. 
 
You asked the Plan to pre-approve PBT. You say that this treatment will help limit exposure to previous 
exposed areas. The Plan denied your request. The Plan says that that it is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 PBT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that as this enrollee had prior radiation to the same site, this would not be a routine case, and 
the need for proton therapy would be plausible. In the setting of reirradiation, particularly when treating target 
volumes close to the heart, proton therapy would be considered to furnished in accordance with accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have been met. Therefore, we decided that the Plan has to pre-approve 
proton beam therapy (PBT) for recurring breast cancer.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Monovisc is covered for certain indications. 
 
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 Monovisc. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has osteoarthritis of the knee. The enrollee received the requested service in March 2023, which is less than six months ago. The coverage criteria are not satisfied. Therefore, the enrollee does not 
meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
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 rehabilitation needs to be fast and efficient so you 
can move towards completing your cancer treatment. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting provided by 
the Plan. The documentation does not support that LTACH services are medically appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service March 12, 2023. 
 
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 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 find that CPT code 99223 is not supported in the medical record. Specifically, code 99223 was billed with 
place of service 21 (inpatient). The documentation shows that the enrollee was in outpatient observation for this 
date of service. This means this code is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 for date of service March 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99214, 96365, 96366, and 96521 billed for 
date of service April 6, 2023. 
 You asked the Plan to pay for procedure code 99214, 96365, 96366, and 96521. You say that you disagree with 
the denial. The Plan denied your request. The Plan says the services are not covered. 
 
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 99214 
is a column II code to column I code 96365. 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.  
 
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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is refilling and maintenance 
of portable pump. 
 
We find that CPT codes 96365, 96366, and 96521 are not supported in the medical record. Specifically, the file 
shows that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more appropriate 
code for these services. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99214, 96365, 96366, and 96521 
billed for date of service April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment (E0431 and E1390) provided on April 
2, 2023. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that you are requesting 
reconsideration for services advising the coding department has reviewed the services and determined that the 
claim is coded correctly. The Plan denied your request. The Plan says R09.02 (hypoxemia) and J96.90 
(respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia), should not be reported 
together which is based on the Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding 
and Reporting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the durable medical equipment 
(DME) have not been met. The diagnosis codes associated to R09.02 and J96.90, should not be reported 
together. The billed service has been denied because it was reported with one or more diagnosis code pairs that 
are subject to an Excludes1 note. Therefore, we decided that the Plan does not have to pay for the oxygen 
equipment (E0431 and E1390) provided on April 2, 2023.
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 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. 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 5, 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 the enrollee requires close daily oversight from a 
physician in an inpatient setting. The Plan denied your request. The Plan says the enrollee does not meet all of 
the requirements. 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.