Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that the enrollee is in much pain. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for this surgery. 
 
The Plan follows Medicare rules. Medicare rules state that lumbar spinal fusion surgery is only covered if 
certain 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 spinal fusion surgery. Our reviewer 
says that the enrollee does not meet criteria for this surgery. Our physician reviewer found the records show 
discogenic back pain without instability or severe stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge management services provided on December 8, 
2022, billed with code 99239. 
 
You asked the Plan to pay for the discharge management services. You say that multiple providers saw this 
enrollee, and all claims should be paid. The Plan denied your request. The Plan says payment was made to 
another physician for the discharge management services. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records shows that 
another physician provided the discharge management services. The Plan has showed that a claim was paid for this physician's services. There is no evidence to support payment for the discharge management services to the 
physician at issue in this case. Based on this information, we decided that Medicare rules for coverage of the 
discharge management services have not been met. Therefore, we decided that the Plan does not have to pay 
for the discharge management services provided on December 8, 2022, billed with code 99239.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee continues to have difficulty ambulating. 
The Plan denied your request. The Plan says continued admission in the SNF does not meet the requirements 
for approval. 
 
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 have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit for the evaluation and 
management (99282) provided on September 27, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. 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 99282 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: An expanded problem focused history; 
An expanded problem focused examination; and Medical decision making of low 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 presenting problem(s) are of low to moderate severity. 
 
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 service. Our reviewer found the review indicates that 
code 99282 was not supported in the medical records. Specifically, there was no medical decision making of 
low complexity. The review has determined that the use of code 99282 was not supported by the records 
provided for September 27, 2022. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department visit for the evaluation and management (99282) provided on 
September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80325, 80345, 80338, 80348, 80346, 80357, 
80356, 80354, 80349, 80361, 80365, 80370, 80363, and 80373 billed for date of service June 23, 2022. 
 
You asked the Plan to pay for procedure codes 80325, 80345, 80338, 80348, 80346, 80357, 80356, 80354, 
80349, 80361, 80365, 80370, 80363, and 80373. You say that you disagree with the denial. The Plan denied 
your request. The Plan says payment for code 80325, 80345, 80338, 80348, 80346, 80357, 80356, 80354, 
80349, 80361, 80365, 80370, 80363, and 80373 is bundled into payment for code G0481.  
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 codes 
80325, 80345, 80338, 80348, 80346, 80357, 80356, 80354, 80349, 80361, 80365, 80370, 80363, and 80373 are 
column II codes to column I code G0481 with a modifier indicator of 0. The column II codes are therefore not 
payable. 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 codes 80325, 80345, 80338, 80348, 80346, 80357, 80356, 80354, 
80349, 80361, 80365, 80370, 80363, and 80373 billed for date of service June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the enrollee needs the device for range of 
motion due to the enrollee's left upper extremity extreme weakness because of the enrollee's right brain stroke. 
The Plan denied your request. The Plan says the device it is considered investigational/experimental. 
 
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 MyoPro Orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollees brachial plexus condition or in widespread use for this enrollees condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 
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 MyoPro Orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous infusion (96365) and ketamine (J3490) 
provided from August 18, 2022, to September 13, 2022. 
 
You asked the Plan to pay for the intravenous infusion and ketamine. You say that the intravenous ketamine 
infusion has changed your life. You also say that this treatment is absolutely needed, and you would like the 
denial to be reversed. The Plan denied your request. The Plan says the services in question are not covered by 
Medicare nor the enrollee's Evidence of Coverage. The Plan also says there is no indicated use of ketamine for 
any psychiatric disorder 
 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 intravenous infusion and ketamine 
have been met. Medical records were not provided for this case. The record shows that the Plan attempted to 
obtain this information, but it was not received. Without medical records we are unable to determine if you 
meet the criteria for coverage. Therefore, we decided that the Plan does not have to pay for the intravenous 
infusion (96365) and ketamine (J3490) provided from August 18, 2022, to September 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis. 
 
You asked the Plan to pre-approve arthrodesis. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services 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 arthrodesis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of spondylolisthesis, spinal stenosis, bilateral sacroiliitis, and 
lumbago. The records show the minuteman device is being used. It is experimental. Also, there is no 
documented spinal instability. 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 arthrodesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823), and batteries 
(E2365 x 2). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the power scooter does not allow for 
activities of daily living (ADLs) or independence. You say that the enrollee has issues with transferring and the 
turn radius is too large. You also say that the enrollee is physically willing and able to operate the power 
wheelchair for ADLs. The Plan denied your request. The Plan says the documentation does not support a 
change in the enrollee's condition. The Plan also says the requested power wheelchair is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our reviewer says 
that a Group 2 power wheelchair is not medically necessary. Our physician reviewer found the enrollee has 
adequate strength to manage a manual wheelchair. The reviewer found that a power wheelchair is not needed to 
manage mobility related activities of daily living. Therefore, the reviewer found that a Group 2 power 
wheelchair 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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair (K0823), and batteries (E2365 x 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from April 13, 2022, to 
May 4, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you believe your claim was filed 
correctly. The Plan denied your request. The Plan says you incorrectly billed an exempt diagnosis in the POA 
section of your claim. 
 
The Plan must follow Medicare rules. Medicare rules say that Present on admission (POA) is defined as being 
present at the time the order for inpatient admission occurs. Claims for inpatient admission to acute care 
inpatient prospective payment system hospitals must include the appropriate POA indicator for the principal 
and all secondary diagnoses, unless the code is exempt. Exempt POA diagnoses should not be reported. 
 
 In this case, you billed diagnosis Z68.41 in the POA indicator section of your claim.  However, diagnosis 
Z68.41 is on the exempt list, meaning that the POA indicator should have been blank. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services provided from April 13, 2022, to May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five additional units of procedure code 77295 billed for date 
of service December 23, 2022. 
 
You asked the Plan to pay for procedure code 77295. You say that you supplied medical records to support the 
services. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan has paid for one unit of this code billed for this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 77295 is 1. The MAI value for this code is 3. You billed 6 units of this 
code for date of service December 23, 2022, exceeding the MUE. You did not provide all the required evidence 
showing that the excess units were actually provided, were correctly coded, and were medically necessary. 
Specifically, the medical records only document one unit of this code being performed on this date of service.  
If you meant to bill for multiple units of this code over a course of multiple days, then a corrected claim would 
be required. Based on this information, we decided that Medicare rules for coverage of procedure code 77295 
have not been met. Therefore, we decided that the Plan does not have to pay for five additional units of 
procedure code 77295 billed for date of service December 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service March 1, 
2022. 
 You asked the Plan to pay for procedure code(s) 88381. You say that you do not believe a modifier is required 
for this service to be paid. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88381. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88381. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88381 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service March 1, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service July 11, 
2022. 
 You asked the Plan to pay for procedure code(s) 88381. You say that you do not believe a modifier is required 
for this claim to be paid. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88381. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88381. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88381 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service July 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital care (99222) provided on November 2, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that 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 99222 is initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and 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 problem(s) requiring admission are of moderate severity. Typically, 50 
minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 service. Our reviewer found the 
physician performed a comprehensive history with chief complaint, history of present illness (HPI) and review 
of systems and details of course after admission. A comprehensive physical exam was performed as defined by 
Medicare as a general exam was performed and moderate decision making was present as there were multiple 
treatment options available and there was data from labs multiple levels for review. 
 
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 service have been met. Therefore, we decided that the Plan has to pay for 
the initial hospital care (99222) provided on November 2, 2022.  
 
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.