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

 
We decided that the Plan has to pay for code 81455 billed for date of service April 30, 2021. 
 
You asked the Plan to pay for code 81455. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says that additional information is needed. 
 
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's sole rationale for denial is that "additional information is 
required." However, in the very brief case file the Plan sent to us, there is no explanation as to what additional 
information is needed and whether or not it was requested.  You included medical records along with your 
appeal request, and there is no evidence in the case file submitted by the Plan that those records were reviewed 
or if they were determined to be deficient in some way.  The burden is on the Plan to show why its denial is 
correct.  By failing to provide any analysis or explanation of what 'additional information' is needed, we find 
that the Plan has not met this burden. Therefore, we decided that the Plan has to pay for code 81455 billed for 
date of service April 30, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are on a lot of oxygen and require IRF level of 
care. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an 
IRF. 
 
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility due to hypoxia with activity. You continue to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that you would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain his functional status. You can receive further services 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at this time the CardioMEMS system would not be considered medically appropriate and 
necessary in this enrollees clinical management. 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 not been met. 
Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code B9002-RR you billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for code B9002-RR. You say that you billed with the required RR modifier, so this 
claim should be paid. The Plan denied your request. The Plan says your claim was missing a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that for capped rental items, providers should bill 
with the RR modifier in addition to a modifier to indicate the month of rental. These modifiers are KH (to 
indicate the first month of rental), KI (to indicate the second and third rental months), and KJ (fourth to the 
13th month). In this case, although you billed the RR modifier, you did not bill a KH, KI, or KJ modifier to 
indicate the month of rental.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code B9002-RR have not been met. Therefore, we decided that the Plan does not have to pay for 
code B9002-RR you billed for date of service August 23, 2022.
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 July 26, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
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 July 26, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 7, 2022, to 
May 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 7, 2022, to May 3, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 2, 2022, to 
March 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 2, 2022, to March 
31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72125 billed for date of service June 12, 
2022. 
 
You asked the Plan to pay for procedure code 72125. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
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 72125 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, 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. Based on this information, we decided 
that Medicare rules for coverage of procedure code 72125 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 72125 billed for date of service June 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 6, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied 
your request. The Plan says 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.   
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81292) provided on June 8, 2022. 
 
You asked the Plan to pay for the lab services (81292). You say that you would like the Plan to reconsider their 
denial of payment. 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 (81292) 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 (81292) provided on June 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (0275T). 
 You asked the Plan to pre-approve percutaneous laminotomy/laminectomy. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar Decompression 
for Lumbar Spinal Stenosis is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve percutaneous 
laminotomy/laminectomy. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the PILD procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous laminotomy/laminectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (0275T).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110, 97530, 97535) provided on January 
18, 2022. 
 
You asked the Plan to pay for therapy services. You say that these services are supported as billed. The Plan 
denied your request. The Plan says the primary diagnosis code submitted on this claim is not appropriate per 
Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that diagnosis codes which are noted as manifestation codes should be coded after an associated 
etiology code.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy services have not been met. Specifically, the primary diagnosis code, F02.80 is a 
manifestation code with a "code first" note indicating possible etiology codes. It is not appropriate to use a 
manifestation code such as F02.80 as a primary diagnosis as the etiology should be coded first. Therefore, we 
decided that the Plan does not have to pay for therapy services (97110, 97530, 97535) provided on January 18, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchman device (CPT code 33340). 
 
You asked the Plan to pre-approve the Watchman device. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Watchman device. Our physician 
reviewer found while there is reference to consideration of the LAAC, there is no documentation of 
performance of an evidence-based shared decision-making interaction on anticoagulation. As such, guidelines 
would not support implantation of a LAAC in this setting. In summary, LAAC placement would not be 
considered reasonable or medically necessary in this enrollee's clinical management. 
 
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 Watchman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Watchman device (CPT code 33340).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization (CPT code 93458). 
 
You asked the Plan to pre-approve the service. You say that this procedure is needed to see if the enrollee 
requires heart surgery. The Plan denied your request. The Plan says the service is 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at this time cardiac catheterization would not be considered medically appropriate and 
necessary in your clinical management. 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 not been met. 
Therefore, we decided that the Plan does not have to pre-approve left heart catheterization (CPT code 93458).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH 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 that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 
 
 
 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CPAP supplies. 
 
You asked the Plan to pre-approve CPAP supplies. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Positive Airway Pressure (PAP) Devices are covered 
when specific criteria are met. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CPAP supplies. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the continuous positive airway pressure (CPAP) device at issue in this case 
meets all Medicare criteria for medically reasonable and necessary for you. Provided records do not document 
adherence to therapy with use of the CPAP =4 hours per night on 70% of nights during a consecutive thirty 
(30) day period anytime during the first three (3) months of initial usage, as required by the Local Coverage 
Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea - 
L33718. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CPAP supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 99215. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99215 is bundled into payment for code 77263. 
 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 code 99215 
is a column II code to column I code 77263. 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 procedure code 99215 billed for date of service May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 0117U for January 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with code 0117U for January 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
29, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this should be paid for. The Plan denied 
your request. The Plan says 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.   
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 29, 2022.