Persius/hicric huggingface dataset:
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 your condition has severely declined and 
admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the member is 
receiving appropriate inpatient acute care and is currently unstable for 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 you continue to receive acute care services, and these have not been denied. The 
medical record does not indicate that you require services that you are not currently receiving but that would be 
available at the LTACH facility.  The requested services 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 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: 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. The Plan denied your request. The Plan says the enrollee's 
ongoing skilled therapy and nursing needs can be provided at a lower level of care, a Skilled Nursing Facility, 
on an intermittent basis at home with home health care, or in a long-term care setting. 
 
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 does not require treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device leads provided on July 7, 2022. 
 
You asked the Plan to pay for the TENS device leads. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the items rendered are not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation did not include a proof of delivery or a delivery ticket. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) device leads provided 
on July 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 26, 2021, 
through August 3, 2021, and billed with diagnosis code J96.21. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis J96.21 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of J96.21. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.21-Acute and chronic 
respiratory failure with hypoxia.. 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 the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support 
secondary diagnosis of J96.21-Acute and chronic respiratory failure with hypoxia. Our physician reviewer 
found the documentation does not consistently and completely support the assigned secondary diagnosis code. 
Therefore, secondary diagnosis code J96.21-Acute and chronic respiratory failure with hypoxia is not the 
appropriate secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 26, 2021, through August 3, 2021, and billed with diagnosis 
code J96.21.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are going to be sent home and do not have 30 
days to wait you need a rehabilitation facility not a nursing home. The Plan denied your request. The Plan says 
your records do not show that you need to be seen by a rehabilitation doctor at least three times a week for 
evaluation of functional and medical goals and progress. The services you need can be provided safely in other 
settings, 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 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. 
 
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 acute inpatient hospital services provided to the enrollee 
from April 30, 2022, to May 4, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
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 the inpatient hospital services at the DRG 
originally billed. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the provided documentation did not reveal sufficient evidence of 
life-threatening organ dysfunction directly related to a dysregulated host response to infection to meet Sepsis 3 
criteria. Also, there was insufficient evidence to suggest MSSA was causing sepsis in this patient. Therefore, 
the diagnoses A41.51 - sepsis due to Escherichia coli and secondary diagnosis code A41.01 - sepsis due to 
Methicillin susceptible Staphylococcus aureus are not supported in the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for acute inpatient hospital services provided to the enrollee from April 30, 2022, to May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 27, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies coded A4595 provided on 
October 20, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the items rendered are not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the proof of delivery did not include an order number or details to corroborate the delivery ticket 
submitted. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies 
coded A4595 provided on October 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 99285. The Plan denied your request. The Plan says payment for 
code 99285 is bundled into payment for code 99291. 
 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 99285 
is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99285 billed for date of service July 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110) and complete 
lower denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures are broken. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 15, 2019. 
Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110) and 
complete lower denture (D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87500, 87640, 87652, 87481) provided on 
May 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim should be covered. The Plan denied your 
request. The Plan says if a laboratory bills for a diagnostic laboratory test and documentation to support the 
medical necessity of the test is not submitted, the claim is denied. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services have been met. The provider did not submit the requested progress notes that were needed in order to determine the clinical utility 
of the testing. The records show that the Plan made multiple attempts to obtain the requested medical records 
without success. Therefore, we decided that the Plan does not have to pay for the lab services (87500, 87640, 
87652, 87481) provided on May 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation beyond the Plan's 24-
trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to 
dialysis appointments. The Plan denied your request. The Plan says you are only covered for 24 routine 
transports. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation beyond the Plan's 24-trip 
limit.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 7, 2022, to June 
29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that the claim must be submitted with the correct type of bill.  
 
We reviewed the file and the Medicare rules. Review of the file shows that this claim was submitted with type 
of bill "322". We find that this is an incorrect type of bill for the services rendered. The claim is not payable as 
billed. Based on this information, we find that the Medicare rules for payment of the claim at issue have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
June 7, 2022, to June 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene 
analysis (81270). 
 
You asked the Plan to pre-approve JAK2 gene analysis. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not have symptoms and findings consistent with 
myeloproliferative neoplasm. 
 
The Plan follows Medicare rules. Medicare rules say that JAK2 gene analysis is considered medically 
necessary in the initial work-up of BCR-ABL and JAK2 (V617F variant) negative adults with clinical, 
laboratory, or pathological findings suggesting polycythemia vera. 
 
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 JAK2 gene analysis. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the enrollee has elevated 
hemoglobin (HGB) and hematocrit (HCT). Molecular testing (blood or bone marrow) for JAK2 V617F 
mutation; if negative, test for CALR and MPL mutations (for enrollees with essential thrombocythemia and 
myelofibrosis) and JAK2 exon 12 mutations (for enrollees with Polycythemia Vera) or molecular testing using 
multigene next generation sequencing (NGS) panel that includes JAK2, CALR, and MPL. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of JAK2 gene analysis have been met. Therefore, we decided that the Plan has to 
pre-approve JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis (81270).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging/single-photon emission 
computed tomography (SPECT). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show any of the covered indications for stress testing with cardiac 
imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of carrying out a radionuclide stress test. The 
patient has no cardiac symptoms. The cardiology consultant felt the electrocardiogram was normal, and cardiac 
function by echocardiogram was also normal. There is no evidence provided that would support the need for 
radionuclide stress testing at this time. In summary, there is insufficient documentation to support the medical 
necessity for the requested cardiac stress testing in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging/single-photon emission computed tomography (SPECT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit (99205) provided on July 26, 2022. 
 
You asked the Plan to pay for a new patient office visit. You say that this was medically necessary. The Plan 
denied your request. The Plan says the enrollee was not a new patient. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that new patient means a 
patient who has not received any professional services, i.e., Evaluation and Management (E/M) service or other 
face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician 
specialty) within the previous 3 years. 
 
In this case, the CPT Code Manual definition of code 99205 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, the record shows that the 
enrollee had received services from this practice on April 11, 2022, meaning the enrollee was not a new patient. 
Based on this information, we decided that Medicare rules for coverage of a new patient office visit have not 
been met. Therefore, we decided that the Plan does not have to pay for a new patient office visit (99205) 
provided on July 26, 2022.