Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve counseling with a licensed professional counselor 
(LPC). 
 
You asked the Plan to pre-approve counseling with an LPC. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested services do not meet the qualifications for coverage under the 
expanded guidelines provided by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that behavioral health services can be furnished under 
general supervision of the physician (or other practitioner) when these services or supplies are provided by 
auxiliary personnel incident to the services of a physician (or other practitioner).  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of counseling with an LPC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve counseling with a licensed professional counselor (LPC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor supplies billed for date of 
service September 22, 2022. 
 
You asked the Plan to pay for the supplies. You say that you have provided medical records and proof of 
delivery to support payment. The Plan denied your request. The Plan says the date of service billed was not 
correct. 
 
The Plan must follow Medicare rules. Medicare rules say that if a supplier utilizes a delivery/shipping service 
or mail order that is able to provide the actual date of receipt by the patient, such date shall be considered the 
date of service on the claim. When the date of actual delivery is not provided, suppliers must use the shipping 
date as the date of service on the claim. In this case, the shipping record shows that the continuous glucose 
monitor supplies in dispute were shipped on September 16, 2022, and delivered on September 20, 2022.  
Neither of these dates matches the date of service that you billed on the claim.  
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
continuous glucose monitor supplies billed for date of service September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99213 for September 13, 
2022. 
 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that post-operative management is included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code 99213 was billed within 10 days of and related to 
minor surgical procedure code 67825 billed on September 6, 2022. Payment for code 99213 is included in the 
global surgical package for code 67825. Therefore, we decided that the Plan does not have to pay for the office 
visit billed with code 99213 for September 13, 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 an Acute Rehabilitation Facility 
to return to prior level of function. The Plan denied your request. The Plan says the enrollee records do not 
show the need for a full time access to a doctor or skilled rehabilitation nurse and are currently at baseline with 
using a wheeled walker, needs can be met at an alternate 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided for use during 
surgery on September 13, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was provided for use 
during surgery to prevent thrombotic events. The Plan denied your request. The Plan says this device was 
provided for a non-covered purpose. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device provided for use during surgery on September 13, 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 requires LTACH admission 
as the appropriate level of care for the best outcome due to complex medical needs. The Plan denied your 
request. The Plan says the required skilled services, routine rehabilitation therapy, local wound care and 
administration of IV medication once daily, can be met safely and effectively at a lower level of care, a skilled 
nursing facility or at home with home health care IV infusion services. 
 
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 presently receiving appropriate services in the acute care 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 25, 2022, billed 
with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321 and 
81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that this panel was medically necessary and 
appropriate. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
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 
February 25, 2022, billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 
81311, 81317, 81321 and 81194.
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. Plan denied your request. The Plan says the enrollee does not 
meet all the required Medicare criteria for admission to an Inpatient Rehabilitation Facility 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve injection. You say that the enrollee has suffered from both midline and para 
midline back pain which is referred somatic pain. The enrollee experiences sitting intolerance, pain reproduced 
with flexion, pain with stand to sit transfer, pain when coughing, sneezing, or bowel movement with an average 
reported pain level of 7 out of 10 on a numeric/visual analog scale. You also say that the enrollee has failed 
conservative treatment such as NSAIDS, analgesics, steroids, opioids, and physical therapy. The Plan denied 
your request. The Plan says the request is not medically necessary because there is little evidence in the 
medical literature to suggest that this is an appropriate procedure for the enrollee's back pain. 
 
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 injection. 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 chronic low back pain. She has had medication trials that have included 
NSAIDs, steroids and opiates. She has done physical therapy. Her MRI shows multi-level degenerative disc 
disease with disc protrusions and annular tears. The request is to inject allograft into these degenerative levels. 
This is considered an experimental and investigational procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, 
unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) electrical stimulator supplies, 2 lead, per month (A4595) provided August 4, 2022. 
 
You asked the Plan to pay for the TENS device and supplies. You say that according to the enrollee's 
prescription, the prescribing physician recommends an extended lifetime use of equipment as they are 
diagnosed with chronic pain and compromised mobility without the option for surgical correction. The Plan 
denied your request. The Plan says the information submitted does not support this level 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 physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the order date is missing from the submitted 
physician prescription order. 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 
transcutaneous electrical nerve stimulation (TENS) device (E0730) electrical stimulator supplies, 2 lead, per 
month (A4595) provided August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0378 provided on April 19, 2022 to May 5, 
2022. 
 
You asked the Plan to pay for procedure code G0378. You say that this service was medically necessary The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0378 is observation services. 
 
We find that CPT code G0378 is not supported in the medical record. Specifically, the claim was submitted 
with an outpatient type of bill (131), however the records show the enrollee was an inpatient at the time this 
service was provided. Based on this information, we decided that Medicare rules for coverage of procedure 
code G0378 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
G0378 provided on April 19, 2022 to May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided September 15, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that E0730 is an accepted procedure 
code according to NCD 280.1. It is impossible for the enrollee to initiate and continue treatment without 
prescribed supplies A4959 as device's design function for treatment require said supplies for regimen. The Plan 
denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply 
code. 
 
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 valid relevant medical records which support medical necessity for the supplies 
provided in this case. Specifically, additional records were needed to support the necessity of the services. 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 electrical stimulator supplies, 2 lead, per 
month (A4595) provided September 15, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 76937, 99291, and 36556. 
We decided that the Plan does not have to pay for the services described by procedure code(s) 93010.  
 
You asked the Plan to pay for the imaging services provided on July 25, 2022. You say that the claim was 
billed correctly and should be paid The Plan says that payment for code 93010 is bundled into payment for 
code 36556. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 76937, 99291, and 
36556.  
 
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 Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 76937, 99291, and 36556.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
93010. 
 
The Plan must follow Medicare rules. The 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 93010 is a 
column II code to column I code 36556. 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. Therefore, we decided that 
the Plan does not have to pay for the services described by procedure code(s) 93010. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99291 billed for date of service July 30, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. The rules also 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. 
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. The file only shows that you 
billed 1 unit of this code on July 30, 2022. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99291 have been met. Therefore, we decided that the Plan has to pay for procedure 
code 99291 billed for date of service July 30, 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: 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 September 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. 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 
September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97530, 97110, and 97012 for July 28, 2022, 
to August 4, 2022. 
 
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 procedure codes 97530, 97110, 97012, and 97530 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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. The definition 
of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop 
strength and endurance, range of motion and flexibility. The definition of code 97012 is application of a 
modality to 1 or more areas; traction, mechanical. The definition of code 97530 is therapeutic activities, direct 
(one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 We find that CPT codes 97530, 97110, and 97012 are not supported in the medical record. Specifically, there is 
no documentation of the specific therapeutic activities performed and the minimum requirement of at least 
eight minutes of therapy for the billed dates of service to support code 97110 and 97530. There is no 
documentation of the type of traction used to support code 97012.  
 
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 97530, 97110, and 97012 for July 
28, 2022, to August 4, 2022.