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

 
We decided that the Plan does not have to pay for procedure code 99217 billed for date of service November 
11, 2022. 
 
You asked the Plan to pay for procedure code 99217. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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. 
 
In this case, the CPT Code Manual definition of code 99217 is: Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]).  

We find that CPT code 99217 is not supported in the medical record. Specifically, the provided records do not 
support that the discharge services at issue were provided on other than the initial admission date. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99217 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99217 billed for date of service 
November 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the level of care provided in the LTACH 
setting is more than the enrollee's medical conditions need.  
 
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 that the record indicates the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules 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 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: Favorable

 
We decided that the Plan has to pre-approve Epifix, per square (sq) centimeter (cm) (Q4186). 
 
You asked the Plan to pre-approve a skin substitute. You say that you were previously progressing with prior 
treatments. The Plan denied your request. The Plan says that the records do not show you have a diabetic, 
stasis, or traumatic ulcer. In addition, the records show you have been treated with the skin substitute since at 
least October 2023 and indicate no response to the therapy. 
 
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 skin substitute. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a chronic sacral wound (greater than 1 year) secondary to paralysis from a fall. At 
issue is coverage of a skin substitute. The documentation suggests that the skin substitute you have been using 
has led to improvement and given the long-standing nature of the wound and exhaustion of more conservative 
therapy, it is medically necessary to continue its use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute have been met. Therefore, we decided that the Plan has to pre-
approve Epifix, per square (sq) centimeter (cm) (Q4186).  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) scan of the abdomen provided on August 
23, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the CT scan is necessary. The Plan denied your 
request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 pay for the CT scan. Our reviewer says that the 
service was medically necessary. Our physician reviewer found you were noted to have right upper quadrant 
abdominal associated with bloating and nausea. You already had your gallbladder removed and recent LFTs 
were normal. An ultrasound of the right upper quadrant is unlikely to provide any diagnostic information. 
Given your prior history of breast cancer and abdominal surgeries, a CT scan of the abdomen is medically 
necessary and reasonable to look for a cause for your pain. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pay for a 
computed tomography (CT) scan of the abdomen provided on August 23, 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 you have submitted a clinical summary and it 
clinically supports this request. The Plan denied your request. The Plan says based on the available 
information, admission to IRF is not reasonable and necessary, as the enrollee's condition does not meet the 
Medicare rules.  
 
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 sepsis, pneumonia, myocardial infarction and supraventricular tachycardia. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. 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 the 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: 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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on the available information, 
admission to IRF is not reasonable and necessary, as the enrollee's condition does not meet the Medicare rules  
 
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 a femur fracture after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. 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 the 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95908 and 95940 rendered on July 31, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is:  
CPT 95940: 
 
Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring 
personal attendance, each 15 minutes (List separately in addition to code for primary procedure) 
 
CPT 95908: 
 
Nerve conduction studies; 3-4 studies 
 
In this case, we have confirmed that code 95908 is a column two code to column one code 95861 with a 
modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that the medical record documents 
"All studies were performed on the aforementioned patient under real-time physician direct supervision via 
internet communication allowing continuous or immediate contact between the interpreting neurologist and 
surgeon".. In this case, there is a more specific code to support for service documented. 
 
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 procedure code 95908 and 95940 rendered on July 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at the psychiatric inpatient hospital 
level of care. 
 
You asked the Plan to pre-approve continued inpatient hospital care. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the records do not show that the enrollee is receiving active 
treatment for a new acute condition. 
 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 continued inpatient hospital care. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the health plans denial 
of continued inpatient psychiatric services appears appropriate. It did not appear that the services for the dates 
in question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. This enrollee was treated under an individualized treatment plan found in the record. It 
appears that the services were supervised and evaluated by a physician. Based upon review the records 
provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment 
beyond the date in question of January 3, 2024, forward and could have been treated in a lesser restrictive 
setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions 
and was not showing any behaviors or aggression being cooperative and compliant while not showing any 
acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continued stay at the psychiatric inpatient hospital level of care.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the records show that the ventilator is going to be used only in a bi-level 
pressure mode as a respiratory assist device (RAD). 
 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 severe COPD with a 
forced expiratory volume (FEV1) of 34% of predicted. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. An arterial blood gas on December 22, 2023, showed a normal pulmonary hypertension 
(pH) and partial pressure of carbon dioxide (PaCO2) of 40. This enrollee does not have evidence of nocturnal 
hypoventilation with chronic cardon dioxide (CO2) retention, and therefore does not meet criteria for a 
respiratory assist device or a home ventilator. The denial is upheld. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33978 rendered on July 24, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a more appropriate CPT code in this case would be 33968. 
 
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 33789 is "Removal of ventricular assist device; 
extracorporeal, biventricular." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that 33978 is not supported. The 
record states that an intraortic ballloon pump was removed. There is a more specific code for this procedure.  
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 procedure code 33978 rendered on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BRCA1, BRCA2 (breast cancer 1 and 2) gene analysis 
(81162) provided November 28, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that BRACAnalysis CDx is covered for patients 
with ovarian cancer, breast cancer, pancreatic cancer and prostate cancer.  The Plan denied your request. The 
Plan says does not meet medical necessity criteria due to no indication that the member has recurrent, relapsed, 
refractory, metastatic, or advanced stage III or IV cancer. 
 
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 pay for the laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not meet any of the indications above unless there are other clinical 
documentation to show the enrollee meets one of the criteria for coverage. 
 
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 laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for BRCA1, BRCA2 (breast cancer 1 and 2) gene analysis (81162) provided November 
28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight manual wheelchair (E1140). 
 
You asked the Plan to pre-approve a lightweight manual wheelchair. 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 a manual wheelchair 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 a lightweight manual wheelchair. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record does not 
support that you require a manual wheelchair to manage self care in the home. 
 
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 lightweight manual wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lightweight manual wheelchair (E1140).