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

 
We decided that the Plan does not have to pay for services identified with codes 99190, 99191, 86891 and 
P9022 provided on February 8, 2022. 
 
You asked the Plan to pay for the codes billed. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable 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 99190, 99191, 86891 and P9022 are not supported in the medical record. Specifically, 
the documentation shows that the enrollee was in a hospital facility from February 8, 2022, to February 10, 
2022. Non-physician Services provided to inpatients which must be furnished directly by the hospital or billed 
through the hospital under arrangements include CPT/HCPCS codes 99190 and 99191 and are to be furnished 
directly by inpatient only hospital and services billed in conjunction with perfusionist services codes 86891 and P9022. This means the services billed are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the codes billed have not been met. Therefore, we decided that the Plan does not 
have to pay for services identified with codes 99190, 99191, 86891 and P9022 provided on February 8, 2022.
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 enrollee's best chance for a quicker 
recovery and more favorable outcome will be with admission to LTACH at this time The Plan denied your 
request. The Plan says a LTACH admission is not medically necessary. 
 
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 has stabilized medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs transfer to treat the 
complex wound care and continued respiratory needs. The Plan denied your request. The Plan says admission 
to LTACH was denied as not meeting criteria, is not medically necessary, and continued acute hospital stay 
was offered. 
 
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 has a medical history including morbid obesity with previous gastric 
bypass who was admitted to the hospital on August 18, 2022 due to sepsis from a dehiscence of prior Roux-en-
Y anastomosis. The enrollee was treated surgically and required support in the intensive care unit. A second 
surgery was required to correct a dehiscence of the fascia. The enrollee currently has a wound VAC for a 
surgical wound, has completed all antibiotics, and requires supplemental oxygen via a nasal cannula. Further 
complications have included pain with sinus tachycardia and diarrhea.  The enrollee has multiple wounds that are not infected. The enrollee does not require services at the LTACH 
that are not available at the acute care hospital or skilled nursing facility. The requested treatments are not 
medically necessary at the LTACH level of care. The enrollee has stabilized medically and can receive further 
care at the current acute care hospital or a lower level of care when deemed appropriate. 
 
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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation in an IRF. The Plan 
denied your request. The Plan says the medical records received shows the enrollee's condition does not meet 
the Medicare guidelines for IRF services. The enrollee's needs can be met in the hospital setting, once the 
enrollee is deemed medically stable a new request for appropriate level of care can be submitted. 
 
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 the enrollee has no medical complexity for a physical medicine and rehabilitation 
physician's supervision 3 times a week. There are no acute rehabilitation nursing needs identified or 
documented. The enrollee with decreased function, at a minimum level for mobility, does not need intensive 
therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. The enrollee needs routine physical therapy and occupational therapy in a skilled nursing 
facility (SNF). 
 
Documentation does not support medical complexity or necessity for admission to an IRF. There are no 
rehabilitation nursing needs. While the enrollee may benefit from continued physical therapy and occupational 
therapy, the enrollee's rehabilitation needs can be safely provided in a lower intensity and alternate setting such 
as in a SNF. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from March 11, 2021, through 
March 14, 2021, at DRG 640. 
 
You asked the Plan to pay for inpatient services at DRG 640. You say that the diagnosis is supported by the 
coding guidelines, documentation, clinical indicators, and treatment as documented. You say that DRG 640 
should be reconsidered. The Plan denied your request. The Plan says diagnosis code J96.90 is not substantiated 
as a valid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.90, defined as respiratory 
failure, unspecified whether with hypoxia or hypercapnia. 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 inpatient services at DRG 640. Our reviewer says that the documentation does not support diagnosis 
code J96.90. Our physician reviewer found that there was no documentation of persistent respiratory 
distress/increased work of breathing, persistent tachypnea, cyanosis, or persistent or progressive dyspnea over 
the enrollees baseline. The physician documented no acute distress in the history and physical and progress 
notes. Therefore, listing respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia, in 
the medical record is not supported by the 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 services provided from March 11, 2021, through March 14, 2021, at DRG 640.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. This patient was recently admitted with 
acute hypoxic respiratory failure, related to a large pleural effusion and heart failure/volume overload. He has 
end-stage renal disease and metastatic renal cell cancer. There are no diagnoses for which Medicare covers a 
home ventilator, such as severe COPD, thoracic restrictive disease, or neuromuscular disease. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 5, 2021 billed with 
codes 81408, 81249, 81226, 81225, 81335, 81227, 81230, 81335, 81241, 81291, and 81240.. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 5, 2021 billed with codes 81408, 81249, 81226, 81225, 81335, 81227, 81230, 81335, 81241, 81291, 
and 81240..
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99213) provided on March 8, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that you changed plans. You 
also say that you cannot pay this bill. The Plan denied your request. The Plan says that the claim processed 
correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Evidence of Coverage does not indicate that there is a 
deductible that applies to covered services. Therefore, we decided that the Plan has to pay for the office visit 
(99213) provided on March 8, 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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 17, 2022, to March 18, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the claim must be completed 
for home health care services to be covered. 
 
 We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
was not submitted with a valid Notice of Admission (NOA). Therefore, we decided that the Plan does not have 
to pay for the home health services provided to the enrollee from February 17, 2022, to March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on April 2, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that this claim should be reprocessed for 
payment. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient hospital services was not filed until April 6, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed.  
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on April 
2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88341, 88342, 88360 and 88381) 
provided on December 20, 2021. 
 
You asked the Plan to pay for pathology services. You say that these services are supported in the medical 
records provided. The Plan denied your request. The Plan says these services were provided to a patient who 
was in an outpatient hospital setting at the time of specimen collection, and therefore these services are missing 
modifiers which are necessary for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88341, 88342, 88360 and 88381 are physician pathology services which have both 
professional components (PC) and technical components. These services were not billed with modifier 26 to 
indicate that only the professional component payment is requested. This means that payment is requested for 
both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
outpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology 
services (88341, 88342, 88360 and 88381) provided on December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro, a powered orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro brace. You say that the device is medically necessary. The Plan 
denied your request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 brace. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested device is used for the upper extremity. It is an arm brace that is motorized and can 
help an individual with upper extremity weakness to move their arm and hand. The requested device has not 
been shown to be superior to other standard treatments for the enrollee's medical condition. The studies do not 
indicate the MyoPro brace improves an individuals function or general health. In order to be considered 
medically necessary a service cannot be investigational or experimental and must be ordered by qualified 
personnel and be appropriate to the enrollees medical needs and condition. Additionally, there must be an 
appropriate duration and frequency that is considered appropriate for the service. 
 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 brace have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro, a powered orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor provided on February 17, 2022. 
 
You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the documentation does not 
support the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the date of service on the claim is February 17, 2022, and the date of service on the invoice is 
February 2, 2022. This means the date of service billed does not match the date of service that the items were 
shipped or delivered. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the supply 
allowance for therapeutic continuous glucose monitor provided on February 17, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on December 
9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that medical necessity is not supported because clinical 
information was not submitted; however, the file contains medical records for the services at issue. Therefore, 
we decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on December 
9, 2021.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the required services can be provided at a lower level 
of care. 
 
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 has remained medically stable and can continue to receive care from 
home health care services or a level of care lower than an LTACH. 
 
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.