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

 
We decided that the Plan has to pre-approve a full night polysomnography (95811). 
 
You asked the Plan to pre-approve the services. You say that this service is medically necessary and 
recommended for the enrollee to have an in-house CPAP titration because of weight loss reports. The Plan 
denied your request. The Plan says that the information submitted does not show that the enrollee meets the 
requirements for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat sleep study can be indicated after 
substantial weight loss has occurred in patients on PAP for treatment of obstructive sleep apnea to ascertain 
whether PAP is still needed at the previously titrated pressure 
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has obstructive sleep apnea. The enrollee reports losing 20 pounds by diet 
modifications. The weight at the most recent visit was 159 pounds. No previous weight is documented. But, if 
there is an assumption that the previous weight was 179 pounds, then a 20 pound weight loss represents an 
11% reduction in body weight, which is sufficient to change PAP requirements, or even eliminate obstructive 
sleep apnea. The repeat titration study is therefore reasonable.  
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a full night polysomnography (95811).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit (99349) for chronic disease management 
provided on June 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit. You say that the services were rendered to the enrollee in good 
faith and were medically necessary. The Plan denied your request. The Plan says the rendering provider is not 
in-network, and no prior authorization was obtained for the date of service. The Plan also contacted the 
enrollees primary care physician (PCP) and confirmed that there is no referral on file for the date of service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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. 
Therefore, we decided that the Plan does not have to pay for a home visit (99349) for chronic disease 
management provided on June 30, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 22, 2022 to May 9, 
2022. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary and 
billed correctly. The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 codes 3HB21, G0299, G0300, Q5001 are not supported in the medical record. Specifically, 
the date on the Notice of Admission does not match the admission date on the claim filed. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided on April 22, 2022 
to May 9, 2022.
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. You say that you would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says the enrollees needs can 
be met at a lower level of care. 
 
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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollees needs are being met in the current inpatient 
setting. The enrollee is not currently being recommended for any lower level of care. The enrollee is best to 
remain in acute as needs are being met. 
 
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 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 LTACH 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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. 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 health plan. The health 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 25, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the codes 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 the denied codes is: 
 
CPT 23195: 
 
Resection, humeral head 
 
 
 CPT 24301: 
 
Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
CPT 23195: resection of humeral head was a separate and distinct procedure from CPT 23472. The procedure 
narrative noted the humeral head was severely comminuted. It was removed piecemeal using a rongeur as well 
as a penetrating towel clip. However, this was performed to allow for the more comprehensive procedure of 
reverse total shoulder arthroplasty to be performed. This was not a distinct procedure. Therefore, the records do 
not support that CPT 23195: resection of humeral head was a separate and distinct procedure from CPT 23472. 
Additionally, the records do not support that CPT 24301: muscle or tendon transfer, any type, upper arm or 
elbow, single (excluding 24320-24331) was actually rendered in this case. The procedure narrative noted the 
biceps tendon was elevated out of the fracture site, whipstitched and stitched in pectoralis major muscle belly 
medial once a tenotomy that was performed to aid in our exposure. This does not support that a muscle or 
tendon was transferred. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 18, 2022, billed with 
codes 81201, 81292, 81295, 81298, 81317, 81314, 81334, 81351, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. 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. 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 
April 18, 2022, billed with codes 81201, 81292, 81295, 81298, 81317, 81314, 81334, 81351, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012) and the electrical 
stimulation (G0283) provided from October 1, 2021, through December 2, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the mechanical traction therapy (97012) and the electrical stimulation 
(G0283) provided from October 1, 2021, through December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 11, 2022. 
 
You asked the Plan to pay for these services. You say that these services should be paid by the Plan. The Plan 
denied your request. The Plan says insufficient medical records were submitted to substantiate the claim and 
several attempts were made by the Plan to obtain these records. 
 
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 lab 
services provided to the enrollee on May 11, 2022. have been met. medical records. Therefore, we decided that 
the Plan does not have to pay for lab services provided to the enrollee on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in intelligent volume-
assured pressure support (iVAPS) mode with Auto-expiratory positive airway pressure (EPAP) (AE) that could 
be delivered by bilevel positive airway pressure (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 the home ventilator. Our physician 
reviewer found provided records document that the home ventilator is being requested for use in IVAPS mode 
with auto-titration which could be provided by a BiPAP device with average volume-assured pressure support 
(AVAPS) and a back-up rate. As stated in the LCD (L33800): Claims for ventilators used to provide CPAP or 
bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of network physician service for the enrollee.  
 
You asked the Plan to pre-approve out of network providers. . You say that this visit is medically necessary for 
the enrollee. The Plan denied your request. The Plan says this service can be provided in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. You are not a 
network provider with the Plan. The Plan has network providers available who can provide these services. We 
found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the 
Plan does not have to pre-approve out of network physician service for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and ready for 
transfer to a LTACH to continue their treatment for their complex medical conditions. The Plan denied your 
request. The Plan says this is not medically necessary and when they are ready to leave the hospital, they can 
safely receive this care in another setting. 
 
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 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning provided on January 6, 2022, by an 
OON provider. 
 
You asked the Plan to pay for advance care planning. You say that the services were rendered to the enrollee in 
the nursing home. You say that the providers rely on the facility staff to verify eligibility and obtain 
authorization from the enrollee's Plan. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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. 
Therefore, we decided that the Plan does not have to pay for advance care planning provided on January 6, 
2022, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you do not believe this code should be 
bundled. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 76700. 
 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 76705 
is a column II code to column I code 76700. 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 76705 billed for date of service April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 26, 2022, billed with 
codes 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare rules. 
 
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 
March 26, 2022, billed with codes 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 
81194 and 81309.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there is an in-network provider that can perform the services the 
enrollee needs. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services to be provided by an out-of-network provider.