Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 9, 2021, billed 
with codes 92540, 92546, 92547, 92653, and 97750. 
 
You asked the Plan to pay for the services as billed. You say that these services should be paid due to medical 
necessity. The Plan denied your request. The Plan says the records do not support the denied codes. 
 
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 92540 is Basic vestibular evaluation, includes 
spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, 
minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral 
stimulation, with recording, and oscillating tracking test, with recording. The definition of code 92546 is 
Sinusoidal vertical axis rotational testing. Code 92547 is defined as Use of vertical electrodes (List separately 
in addition to code for primary procedure). Code 92653 is defined as Auditory evoked potentials; 
neurodiagnostic, with interpretation and report. Code 97750 is Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes. 
 
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 as billed. Our reviewer says that the billed 
services at issue are not supported by the records. Our reviewer found regarding code 92540 and 92546, the 
records do not include documentation of these services being rendered. As for 92547, this is an add-on code to 
the prior two and cannot be paid as the primary codes are not supported. For 92653, the medical record does 
not include documentation of electrodes placed on scalp and earlobes and delivering auditory stimuli with 
interpretation and report. Therefore, this procedure cannot be verified. The records also do not support that the 
services described by code 97750 were rendered.  
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on December 9, 2021, billed with codes 92540, 92546, 
92547, 92653, and 97750.
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have any parental medication; complex wound care or nutrition 
given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. 
Her physical function is at or near her baseline. She does not require skilled nursing and/or skilled therapy 
services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. 
Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (CPT code(s): 81162, 81317, 81298, 
81321, 81292, 81295, 81301, 81191, 81401 and 81206) provided on November 16, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the claim should be paid. 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.  
 
This request represents apparent claim unbundling and is not allowed by Centers for Medicare & Medicaid 
Services (CMS). Per Medicare guidelines, Local Coverage Article A57880, it is not appropriate to bill 
individual CPT codes for a single panel. If a laboratory assays 2 or more genes in a patient in parallel, then 
those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so 1 HCPCS codes must be submitted for the panel. Medicare says if a single procedure is performed, 
only one code with one unit of service may be reported for the procedure. Therefore, we decided that the Plan 
does not have to pay for the genetic testing (CPT code(s): 81162, 81317, 81298, 81321, 81292, 81295, 81301, 
81191, 81401 and 81206) provided on November 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 3, 2022, 
through March 28, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
A required data element for submission of claims under home health PPS was invalid. Per the members claims 
history, a NOA claim with a one-time, artificial 'admission' date was reported for January 02, 2022. Subsequent 
reporting of the admission/start of care date on the 30-day period of care claim is reported as December 03, 
2021. Therefore, as the required data element admission/start of care date, on this subsequent period of care 
claim does not match the one-time, artificial 'admission' date of the first visit reported on the NOA claim we 
find the Medicare rule for reimbursement of this March 03, 2022, through March 28, 2022, claim has not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
March 3, 2022, through March 28, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the pelvis for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically- The Plan denied your request. The 
Plan says that there is no clinical suspicion for pathology in the pelvis, and no previous imaging abnormality 
that requires follow-up. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that while there is a low 
suspicion of recurrence, the enrollee has not had an imaging study of pelvis within the past year. The MRI of 
the pelvis will enable evaluation of pelvic lymph nodes, lower ureter, bladder and bowel. The primary tumor 
was carcinoid and the possibility of metastatic disease in a patient with multiple pulmonary nodules would 
require imaging of the abdomen and pelvis in addition to the approved computed tomography of the chest. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the pelvis for the enrollee.  
 
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records 
provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees medical conditions appear stable on outpatient medications with no issues that appear to require a physicians 
evaluation three or more times per week. The enrollee does require physical therapy and occupational therapy 
services, but the medical records provided do not clarify why the enrollee requires an intensive inpatient 
rehabilitation therapy program. Provided medical records do not explain why the intensive inpatient 
rehabilitation therapy program is necessary and why therapy at a lower level of care such as in a skilled nursing 
facility is not appropriate for the enrollee. Based on the medical records provided there is no support in the 
documentation that the enrollee requires the intensive medical care and 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a BiPAP machine with AVAPS capability. The plan has indicated coverage 
for such a device is available upon request. The elements of the coverage criteria are not satisfied. The 
requested service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Micra device. 
 
You asked the Plan to pre-approve a Micra device. You say that the services are necessary. The Plan denied 
your request. The Plan says the enrollee is not in a Medicare approved clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that effective January 18, 2017, the Centers for 
Medicare & Medicaid Services (CMS) covers leadless pacemakers through Coverage with Evidence 
Development (CED). CMS covers leadless pacemakers when procedures are performed in Food and Drug 
Administration (FDA) approved studies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Micra device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Micra device.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for more eyeglasses provided on May 4, 2022. 
 
You asked the Plan to pay for more the eyeglasses. You say that you are requesting reconsideration of the 
claim. The Plan denied your request. The Plan says that the claim paid correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan contract says you have a choice of a $300 (combined in and out-of-network) benefit toward 
the purchase and fitting of eyeglasses and pair of lenses or contact lenses (one per calendar year). 
 
We looked at the file and the Plan's rules. Specifically, the case file is unclear if the Plan has paid up to the 
$300 benefit for these services. The Plan must pay more for these services, and they must pay $300 for them. 
The health Plan contract does not describe the $300 annual benefit as a discount towards the retail price for 
service. The Plan has to pay this amount each year. The enrollee is responsible for any amount over $300, 
which appears to be $172.80. Based on this information, we decided that the Plan's rules for coverage of the 
eyeglasses have been met. Therefore, we decided that the Plan has to pay for more eyeglasses provided on May 
4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition you do not meet the requirements. 
 
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 you were admitted for a surgical repair of a hip fracture after a fall, chronic kidney 
disease and COVID-19 infection. Medical problems are stable.  
 There are no complex nursing or rehabilitation needs. While you have a need for physical or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition you do not meet the requirements. 
 
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 you were admitted for lumbar spinal surgery. Medical problems are stable. There are 
no complex nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says that admission to the IRF is not medically necessary and 
the enrollee's need can be met in a lower level of care like a skilled nursing facility (SNF). 
 
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 is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. No acute rehabilitation nursing needs identified 
or documented. At the current functional level, the enrollee does not need intensive therapies consisting of at 
least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. 
 
The Documentation does not support necessity for admission to an IRF as there is no medical complexity or 
nursing needs. While the enrollee may benefit from continued physical therapy and occupational therapy the 
enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in an SNF or in-
home with services and family support. 
 
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 IRF admission and services.
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no documentation of new enteral feedings, complex wound care or other SNF 
nursing need. The 10/16/22 progress note indicates the enrollee was coughing and concerned for pneumonia so 
a chest x-ray was ordered which should be followed and managed in acute care prior to any discharge to 
rehabilitation. The enrollee was a febrile and had no leukocytosis suggestive of a pneumonia. He has no cardiac 
etiology for chest pain, is hemodynamically stable, has resolved acute kidney insufficiency, and has controlled 
pain. The enrollee's functional level is near baseline, and he has declined therapy on several occasions. He does 
not require skilled therapy services with the specialized skill, knowledge, and judgment of a qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
require skilled nursing or skilled therapy on a daily basis or as a practical matter in a SNF. 
 
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.