Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special supplies and materials rendered on June 21, 2021 
to August 16, 2021. 
 
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 are 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 CPT code. 
 
We find that CPT code 99070 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99070 is not separately payable. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the special 
supplies and materials rendered on June 21, 2021 to August 16, 2021.
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 IRF care is needed to improve your walking pattern 
and to prevent you from falling or a fracture. The Plan denied your request. The Plan says the guidelines for 
coverage have not been met. The Plan says that the enrollee can safely receive the services needed in other 
settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has a past medical history of stroke with hemiparesis in 2019, diabetes, hypertension and bipolar disorder and 
is living at home with weakness and difficulty with self care. The enrollee's medical problems are stable. There 
are no 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a critical care visit (99291) provided on June 27, 2021. 
 
You asked the Plan to pay for critical care visit. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the records 
submitted do not include documentation of the time spent with the patient so code 99291 cannot be verified. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30 to 74 minutes. 
 
 
 
 
 
 
 We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not include 
the time spent with the enrollee to support a critical care duration of 30 to 74 minutes. Based on this 
information, we decided that Medicare rules for coverage of critical care visit have not been met. Therefore, we 
decided that the Plan does not have to pay for a critical care visit (99291) provided on June 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health office visits provided on June 2, 
2021, to August 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health office visits. You say that you were not aware that 
the provider was out-of-network. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for outpatient mental health office visits provided on June 2, 2021, 
to August 11, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections. 
 
You asked the Plan to pre-approve the facet joint injections. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that 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 facet joint injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found according to the coverage 
criteria, facet injections are indicated when there is no non-facet pathology per clinical assessment or radiology 
studies that could explain the source of the patients pain, including but not limited to fracture, tumor, infection, 
or significant deformity.  In this case, the enrollee's MRI demonstrates lumbar spinal stenosis and severe 
bilateral neural foraminal stenosis. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and your lungs were clear. You were at an independent to supervision/touch assist level for functional 
mobility including gait. You do not require skilled nursing or therapy services on a daily basis. You do not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radionuclide stress testing (SPECT). 
 
You asked the Plan to pre-approve SPECT. You say that there are mild emphysematous changes, severe 
coronary artery and aortic valvular calcification, and the ascending thoracic aorta measures 3.5cm in diameter. 
The Plan denied your request. The Plan says the requested imaging services are not medically reasonable and 
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 SPECT. Our reviewer says that SPECT 
is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee 
has a history of previous radionuclide stress test in 2018 which was negative for ischemia. The enrollee has not 
had chest pains and there is no documentation of any significant change in her clinical cardiac condition in the 
interim. The enrollees pre-test probability for an abnormal test is low and there is no documentation that the 
electrocardiogram (ECG) shows an uninterpretable pattern. There is no evidence provided that would support 
the need for radionuclide stress testing. In summary, there is insufficient documentation to support the medical 
necessity for the requested cardiac stress testing 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 SPECT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radionuclide stress testing (SPECT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interpretation of a computed tomography (CT) scan of the 
head provided on January 24, 2022, billed with code 70450-26. 
 You asked the Plan to pay for the CT scan interpretation. You say that this code should be paid because 
multiple exams were provided on the same date of service. The Plan denied your request. The Plan says the 
code at issue was not billed with a clinically appropriate modifier to bypass the PTP edit with 70496. 
 
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 70450 is a column II code to column I code 70496. 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 interpretation of a 
computed tomography (CT) scan of the head provided on January 24, 2022, billed with code 70450-26.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found you have complex medical monitoring needs per provider documentation that warrant an inpatient stay 
with 3 physician face to face visits per week. You have complex functional impairments with history of 
amputation and prosthesis not currently fitting as documented by evaluating therapist. The therapist documents 
evidence of your ability to benefit from and participate in an intensive rehabilitation regimen of 3hr per day, 5 
days per week. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 targeted genomic sequence analysis rendered on April 
21, 2021. 
 
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 not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee had a diagnosis of 
unspecified anemia. There is no documentation in the submitted records supporting that the criteria for 
coverage were met. The testing was not reasonable or medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the targeted genomic sequence analysis rendered on April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting (76377) 
provided on November 16, 2021. 
 
You asked the Plan to pay for code 76377. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 76377 is not supported in the medical record. Specifically, the governing LCA includes 
a list of secondary diagnosis codes which are required to support the medical necessity of CPT code 76377. 
This claim has not been billed with an appropriate secondary diagnosis code.  
 
 Therefore, we decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting 
(76377) provided on November 16, 2021.
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 services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 while the enrollee may benefit from physical therapy or occupational therapy, the 
enrollee's needs can be met 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (81455) provided 
August 23, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that molecular testing was requested directly from 
the treating physician who makes the professional determination of diagnosis and medical necessity to 
successfully treat the enrollee. The Plan denied your request. The Plan says does not meet Medicare NCD/LCD 
criteria. Targeted genomic sequence analysis panel is not covered by Medicare. 
 
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 say that genetic testing procedures submitted with 
code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and 
will be denied automatically as not medically necessary. 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 targeted genomic sequence analysis panel (81455) provided August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on August 6, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because code 84480 is not 
separately payable and these tests were not billed with the appropriate Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 lab tests 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 laboratory testing provided on August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services on September 8, 2021. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services 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 the laboratory services on September 8, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 0202U) provided from 
November 11, 2021, through November 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered by Medicare or the health plan. 
 
 
 
 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Per the Medicare 
guidelines procedure code 0202U is listed as a non-covered service and is not appropriate to bill Medicare. 
Therefore, we find the Medicare rule for payment of procedure code 0202U for this November 11, 2021, 
through November 12, 2021, claim has not been met. If the provider determines that a billing error occurred 
during the initial submission of the denied claim, the plan will accept a submission of a corrected claim to 
consider service for payment. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (CPT code 0202U) provided from November 11, 2021, through November 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does 
not require skilled nursing or therapy services on a daily basis. The enrollee's needs can be met 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 the skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.