Persius/hicric huggingface dataset:
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 needs IRF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the IRF services requested do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has no acute medical complexity and no acute rehab nursing needs for an IRF admission. The enrollee needs routine physical therapy and occupational therapy at a lower 
intensity. While the enrollee would benefit from physical therapy and occupational therapy, rehabilitation 
needs can be safely met in an alternate and low intensity setting such as in-home with services or 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 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: 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to be more stable and should only require short-term additional acute care 
services that can safely be provided at the current facility until more appropriate for a lower level of care soon. 
There are no services at the LTACH that you require that are not already available and covered at the current 
facility. Transfer to the LTACH is not medically necessary 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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensive outpatient psychiatric services (S9480). 
 
You asked the Plan to pre-approve intensive outpatient psychiatric services. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says the code to be used for the 
requested services is invalid for Medicare purposes. 
 
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 procedure code S9480 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9480 is not valid for Medicare purposes. It is unclear in the case record what specific, 
potentially coverable subservices are being requested. You have the right to request different codes that are 
potentially coverable from the Plan directly, for example, codes for group outpatient therapy, etc. Based on this 
information, we decided that Medicare rules for coverage of intensive outpatient psychiatric services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve intensive outpatient psychiatric 
services (S9480).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oncology (urothelial), mRNA, gene expression profiling 
by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing 
urine, algorithm reported as a risk score for having urothelial carcinoma (0012M) provided November 23, 2021 
 
You asked the Plan to pay for the CxBladder Detect test. You say that you are writing to appeal the denial of 
coverage for the Cxbladder Detect test for the enrollee. The Plan denied your request. The Plan says review of 
the medical literature and clinical practice guidelines does not support the clinical utility of CxBladder Detect. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the CxBladder Detect test have not been met. Therefore, we decided that the Plan does not have to 
pay for the Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five 
genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm reported as a risk 
score for having urothelial carcinoma (0012M) provided November 23, 2021
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 4, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. 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 4, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Belatacept (J0485). 
 
You asked the Plan to pre-approve Belatacept. You say that Belatacept is medically necessary. The Plan denied 
your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Immunosuppressive drugs are covered only for the 
specific labeled indications and approval for marketing by the FDA. 
 
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 Belatacept. Our reviewer says that 
Belatacept is medically necessary. Our physician reviewer found the enrollee was placed on Belatacept and has 
been doing fine on this drug since November 2020. Review of the literature indicates that Belatacept has no 
FDA-approved indications for use in lung transplatations, however, Belatacept has been used in this setting for 
the purpose of renal sparing when alternative therapies were ineffective or when contraindications exist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Belatacept have been met. Therefore, we decided that the Plan has to pre-
approve Belatacept (J0485).  
 
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 pay for the acute inpatient hospital care associated with removal of 
external fixation system along with right tibia fracture intramedullary nailing procedure. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee needs inpatient care. The 
Plan denied your request. The Plan says the enrollee's surgery does not need this level of hospital treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that this tibia fracture surgery may be safely performed with a 48-hour observational 
stay. An inpatient admission is not 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care associated with removal of external fixation 
system along with right tibia fracture intramedullary nailing procedure.
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 meets LTACH criteria. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
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 all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services (76641) provided on July 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the MUE value of 
1 has been exceeded. 
 
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 argues that code 76641 has an MUE of 1, however, a CPT code search 
reveals that code 76641 has an MUE value of 2. Additionally, Medicare rules say that a bilateral diagnostic 
procedure may be reported with 1 unit of service with modifier RT on 1 claim line plus 1 unit of service 
and modifier LT on a second claim line, as was done in this case. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (76641) provided 
on July 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Lynch Syndrome Panel billed with codes 81317, 
81292, 81298, 81295, 81300, 81319, and 81294 provided on August 30, 2022. 
 
You asked the Plan to pay for the panel testing. You say that the results of the testing were necessary in the 
enrollee's medical management. The Plan denied your request. The Plan says this testing should be billed with 
a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that panels should be billed with a single panel code. 
 
We looked at the file and Medicare rules. This 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 panel testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Invitae Lynch Syndrome Panel billed with 
codes 81317, 81292, 81298, 81295, 81300, 81319, and 81294 provided on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as U0003 and U0005, provided 
May 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that due to the global pandemic, your billing 
department was understaffed. The other reason for the reconsideration request is that in October 2021, you 
were also a victim of a ransomware attack. The Plan denied your request. The Plan says the claim was received 
past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until May 12, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as U0003 and U0005, provided 
May 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 30, 
2021, to December 31, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that it was medically necessary to treat the 
enrollee at the inpatient level, and this admission was warranted. The Plan denied your request. The Plan says it 
was not medically necessary for the enrollee to be admitted as an inpatient for the dates in question; the care 
provided would be more appropriate as outpatient care. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 30, 2021, to December 
31, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
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 not been met. Therefore, we decided that the Plan 
does not have to pre-approve five home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronary calcium screening computed tomography (CT) scan provided on September 26, 2022.

You asked the Plan to pay for the coronary calcium screening CT scan. You say that you would like this service to be reconsidered under your reimbursement program. The Plan denied your request. The Plan says reimbursement for medical procedures, such as coronary calcium screening CT scans, is not covered by the Plan.

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 test at issue in this appeal, the coronary calcium screening CT scan, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. However, your plan offers a supplemental benefit for specific items. Coronary calcium screening CT scan is not listed as a covered benefit under the supplemental reimbursement program. Therefore, we decided that the Plan does not have to pay for the coronary calcium screening computed tomography (CT) scan provided on September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on July 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 drug testing services (G0483) provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on January 13, 2022, to June 1, 2022.

You asked the Plan to pay for the dental services. You say that you are filing this appeal. The Plan denied your request. The Plan says services provided by an out-of-network provider are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The record shows you received the requested dental services from an out-of-network provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for dental services provided on January 13, 2022, to June 1, 2022.