Persius/hicric huggingface dataset:
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 meets the Medicare criteria 
for LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
guidelines for LTACH admission, and they are receiving the medically necessary care they need in the current 
facility they are in. 
 
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 enrollee appears to be improving but still unstable and should only require 
short-term additional acute care services that can be safely administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the 
enrollee is still unstable and as it would not be clinically advantageous at this time. Completion of treatment at 
the current facility is recommended. 
 
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: 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 would benefit from the rehabilitation 
they would receive in a SNF. The Plan denied your request. The Plan says that the criteria for admission to a 
SNF was not met and the enrollee can receive the services they need in a long term-care facility. 
 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 that the enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. The enrollee is ambulating and tending to activities of daily living 
with minimal supervision. Daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. The enrollees care needs can, as a practical matter, be 
provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 36819 billed for dates of service February 2, 2022, to 
February 3, 2022. 
 
You asked the Plan to pay for code 36819. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says procedure code 36819 is not supported in the medical record. The 
operative report supports a second stage revision was performed of the arteriovenous graft in which the basilic 
vein was transposed via vasovasostomy. There is a more appropriate code for the open revision of the 
arteriovenous fistula (AVF) with basilic vein transposition for the stage 2 portion of the procedure. The initial 
surgery would be reported as a creation; the second surgery is considered a revision of the initial first stage 
brachioradialis AVF creation surgery and should be reported with code 36832 instead of 36819. 
 
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 36819 is Arteriovenous anastomosis, open; by upper arm 
basilic vein transposition. 
 
 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 code 36819. Our reviewer says that code 36819 is not 
supported in the medical record. Our reviewer found medical records do not support the use of procedure code 
36819. There is a more appropriate code that can be coded to justify the documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 36819 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 36819 billed for dates of service February 2, 2022, to February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical boot/shoe provided on May 26, 2022 by an out-
of-network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the surgical boot/shoe provided on May 26, 2022 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on March 15, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed 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. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the date the specimen was 
collected (February 27, 2022) does not match the date of service billed. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for genetic testing (81479) provided on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with this denial and 
you believe these services were medically necessary. The Plan denied your request. The Plan says not covered 
per Medicare NCD. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 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. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve the home health skilled nursing visits (CPT code G0299 x3). 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says that the enrollee's records do not support the need for a skilled nurse to 
make more visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found clinical documentation shows that in addition to urinary retention, and other stable 
comorbidities, the enrollee has skin breakdown with mobility impairments and requires assessment for urinary 
tract infection (UTI) symptoms as documented; thus, three (3) additional skilled nursing visits are 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 home health services have been met. Therefore, we decided that 
the Plan has to pre-approve the home health skilled nursing visits (CPT code G0299 x3).  
 
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: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve SNF care through October 6, 2022. We decided that the Plan does 
not have to pre-approve SNF care after October 6, 2022.  
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee has multiple health issues and 
is not healthy enough to go home on their own. The Plan says that criteria for a continued SNF stay have not 
been met. Skilled services can be provided on an intermittent outpatient basis, in a long-term care facility, or at 
the home with home health care services. 
 
We decided that the Plan has to pre-approve SNF care through October 6, 2022.  
 
Our reviewer says that based on the documentation provided, the enrollee qualifies for SNF coverage through 
October 6, 2022. Our reviewer found that the enrollee made measurable progress between September 28, 2022, 
and October 6, 2022. After this date, the enrollee did not have documented skilled nursing needs or skilled 
therapy needs and their care needs could be provided at a lower level of care Therefore, we decided that the 
Plan has to approve SNF care through October 6, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee has a past medical history of diabetes and a below the knee amputation and is living at home with 
difficulty ambulating. The enrollees medical problems are stable. She does not have 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 this 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided March 14, 
2022. 
 
You asked the Plan to pay for the Cxbladder Detect testing. You say that this test is medically necessary and 
covered. The Plan denied your request. The Plan says this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Detect testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided March 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria at a dose of 2mg/kg to be given every 6 
weeks. 
 
You asked the Plan to pre-approve Simponi Aria at a dose of 2mg/kg to be given every 6 weeks. You say that 
the requested Simponi Aria at a dose of 2mg/kg to be given every 6 weeks is medically necessary as this is 
more than the maximum allowed dose for the enrollee's indication. The Plan denied your request. The Plan says 
the requested Simponi Aria at a dose of 2mg/kg to be given every 6 weeks is not medically necessary as this is 
more than the maximum allowed dose for the enrollee's indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Simponi Aria at a dose of 2mg/kg to be 
given every 6 weeks. Our reviewer says that the requested Simponi Aria at a dose of 2mg/kg to be given every 
6 weeks is not medically necessary as this is more than the maximum allowed dose for the enrollee's indication. 
Our physician reviewer found the documentation does not support that Simponi Aria at a dose of 2mg/kg to be 
given every 6 weeks is safe and effective for the enrollee. The requested Simponi Aria at a dose of 2mg/kg to 
be given every 6 weeks is not medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria at a dose of 2mg/kg to be given every 6 weeks have not been met. Therefore, we decided that the Plan does not have to pre-approve Simponi Aria at a dose of 2mg/kg to be given 
every 6 weeks.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transport services provided on May 7, 2022. 
 
You asked the Plan to pay for ambulance transport services. The Plan denied your request. The Plan says that 
when a Plan member elects to enroll in the Medicare Hospice Program, Original Medicare assumes 
responsibility for payment of all hospice-related and all non-hospice related services rendered during the 
election period. 
 
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 has not provided us with proof of hospice enrollment. 
Therefore, we decided that the Plan has to pay for ambulance transport services provided on May 7, 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 genetic testing provided on February 13, 2022 billed with 
codes 81210, 81206, 81272, and 81235. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
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 13, 2022 billed with codes 81210, 81206, 81272, and 81235.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standby services (99360) provided on April 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the facility claim. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for inpatient hospital services 
under the Inpatient Prospective Payment System (PPS). These amounts are, with certain exceptions, payment in 
full to the hospital for inpatient operating costs. All items and non-physician services furnished to inpatients 
must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. Payment for the requested services is included under the facility 
claim. These services are not separately payable. 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 the 
standby services (99360) provided on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6196 and A6197 billed for date of service 
October 6, 2020. 
 
You asked the Plan to pay for procedure codes A6196 and A6197. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says procedure codes A6196 and 
A6197 are considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that codes A6196 and A6197 have a status code of "P" under the Medicare Physicians Fee Schedule 
Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as payment is 
bundled into the payment for the services to which these codes are incident to. Therefore, we decided that the 
Plan does not have to pay for procedure codes A6196 and A6197 billed for date of service October 6, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81455) provided on May 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that generally laboratory services should be billed with the 
date of specimen collection as the reported date of service; however, there are three exceptions to this rule. 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.  
 
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 has not acknowledged nor addressed the possible 
exceptions to the rule applied in this case. The sample in this case was collected as part of a biopsy procedure 
performed in an outpatient hospital setting, so it is likely that an exception has been met in this case. Therefore, 
we decided that the Plan has to pay for the laboratory services (81455) provided on May 22, 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.