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

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that the requested SNF services are not medically 
necessary. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that the enrollee had functional and clinical 
status changes and skilled nursing and therapy assessment would be medically appropriate. Skilled therapy 
evaluations recommend ongoing skilled therapy in a SNF (the latest notes state that the enrollee requires 
minimal assistance with the activities of daily living (ADL), is still confused, and is on supplemental oxygen.) 
Thus, the enrollee would be expected to require daily skilled services on an inpatient basis in a skilled nursing 
facility. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 
14, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided to 
prevent embolisms during the patient's surgery. The Plan denied your request. The Plan says equipment used in 
a medical facility that is not the patient's home is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. This item was provided solely for use in an 
outpatient facility, not for use in the patient's home. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 31, 2022. 
 You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on March 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (92526, 92610 and 97535) provided from 
April 19, 2022, to April 27, 2022. 
 You asked the Plan to pay for therapy services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says the services billed with procedure code 97535 
were reported with revenue code 0430, but do not include the GO modifier. These services are denied as billed, 
and this claim is returned to the provider for correction. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that certain therapy codes must be reported with the GN, GO or GP modifier to distinguish the 
discipline of the plan of care under which the service is delivered. The rules also say that contractors edit 
institutional claims to ensure that a GN, GO, or GP modifier is present for all lines reporting revenue codes 
042X, 043X or 044X. Contractors return to the provider institutional claims that do not meet this condition. 
 
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 documentation shows that code 97535 was 
reported with revenue code 0430, but these lines/services do not include the appropriate GN, GO or GP 
modifier. Therefore, these services are denied. In addition, the rest of the claim is returned to the provider for 
correction as billing rules have not been met. Therefore, we decided that the Plan does not have to pay for 
therapy services (92526, 92610 and 97535) provided from April 19, 2022, to April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4253 and A4259 billed for date of service 
January 10, 2022. 
 
You asked the Plan to pay for procedure codes A4253 and A4259. 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 codes A4253 and A4259 is 1. The MAI value for this code is 3. You billed 4 
units of code A4253 and 2 units of code A4259, 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 A4253 
and A4259 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
A4253 and A4259 billed for date of service January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99309) provided on August 18, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not pre-authorized or emergent. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for nursing facility care (99309) provided on August 18, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for lead wires (A4557) provided on September 3, 2022. 
 
You asked the Plan to pay for the lead wires. You say that these items were medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
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 did not fully articulate the reason for the denial. The plan did not cite 
the Medicare policy or regulation used to make the determination. Therefore, we decided that the Plan has to 
pay for lead wires (A4557) provided on September 3, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech therapy. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says based on the clinical information received, the enrollee 
previously completed the SPEAKOUT! program and they can speak at a normal loudness. The documentation provided does not indicates the requested therapy reasonable nor necessary given your ability to speak. 
 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the enrollees condition beyond what was approved by the health plan. The enrollee 
has had prior therapy and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve speech therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for addiction management services (90853) provided on May 3, 
2022. 
 
You asked the Plan to pay for addiction management services. You say that this claim should be processed. 
The Plan denied your request. The Plan says the provider in this case is a non-Medicare approved/certified 
Substance Abuse Rehabilitation Facility, and therefore no Medicare payment may be made. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for addiction management services (90853) 
provided on May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prostheses, flex-walk system or 
equal (L5981). 
 
You asked the Plan to pre-approve a flex-walk system. You say that the current prosthesis requires replacement 
due to wear and because no adjustments nor repairs are possible to restore its function for the enrollee. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the requested item. 
 
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 flex-walk system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the flex-walk system exceeds the enrollee's medical needs and is not medically 
necessary per Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) and per Social Security 
Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k). The treating medical physician provider documentation 
does not support that the enrollee is a K3 ambulator. 
 
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 flex-walk system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an all-lower extremity prostheses, flex-walk system or equal (L5981).
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 is unable to go home and live alone. The 
enrollee had had laryngectomy surgery and needs help to become stable. The Plan denied your request. The 
Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care 
such as a skilled nursing facility, home with home health services, or home with outpatient therapy. 
 
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 enrollee was admitted to the hospital for surgical treatment of the bleeding from 
flap reconstruction. The enrollee had a complex hospital stay that included mechanical ventilation and a cardiac 
arrest resulting from problems with his tracheostomy tube. The enrollee is medically stable. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HBA1/HBA2 (alpha globin 1 and alpha globin 2) gene 
analysis (81257). 
 
You asked the Plan to pre-approve HBA1/HBA2 gene analysis. You say that this test is medically necessary 
and appropriate. The Plan denied your request. The Plan says this test 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 HBA1/HBA2 gene analysis. 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 microcytosis without anemia. The provider wants 
to check for alpha thalassemia. HBA1/HBA2 deletion/duplication testing is considered to be reasonable and 
necessary for patients with a protein-based hemoglobin analysis suggestive of alpha thalassemia. In this case, the records do not show a protein-based hemoglobin analysis suggestive of alpha thalassemia. The review has 
determined that the items/services at issue in this case are not medically reasonable or 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 HBA1/HBA2 gene analysis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve HBA1/HBA2 (alpha globin 1 and alpha globin 2) gene analysis (81257).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found an Intracept procedure is experimental. More research is normal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
November 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should bep aid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records submitted did 
not support that there was a comprehensive history. The denied code is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on November 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DermTech PLA oncology testing (0089U) provided on 
August 17, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial and request 
reconsideration for payment on this claim. You also say documentation supports medical necessity. The Plan 
denied your request. The Plan says the requested testing does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules show that there are specific characteristics that the 
lesion must have to be approved for the requested testing. The records do not show that the enrollee has any 
ABCDE criteria or that the lesions are in areas where the skin is intact. Based on this information, we decided 
that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for DermTech PLA oncology testing (0089U) provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (0239U) provided on November 14, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that you are an independent laboratory and you do 
not have direct access or interaction with the enrollees prior to the time of service. Therefore, you are not 
responsible for obtaining prior authorization and requesting that the Plan reconsider payment. The Plan denied 
your request. The Plan says records detailing the enrollee's diagnosis, disease progression, treatment plan, and 
potential impact of these test results on clinical decision making were not included. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file and Medicare rules. The records do not show that there is documentation to show why the 
tissue was tested or how the results will impact future treatment planning. Medical records were not submitted. 
The records also show that prior authorization was not requested. Based on this information, we decided that 
Medicare rules for coverage of laboratory testing have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory testing (0239U) provided on November 14, 2022.