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 the enrollee will require longer time to 
continue weaning from a ventilator and to transition from acute illness. The Plan denied your request. The Plan 
says when the enrollee's 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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on September 23, 
2022. 
 
You asked the Plan to pay for the critical care services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 services. 
 
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 critical care services. Our reviewer says that the records 
do not support the code billed. Our reviewer found the code definition and description for critical care services 
involves acute impairment of one or more vital organ systems, such that there is a probability of imminent or 
life-threatening deterioration of the patient's condition. A provider reporting critical care services the same day 
the patient is discharged to home from the emergency room is not 
expected.  
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 critical care services have not been met. Therefore, we decided that the Plan 
does not have to pay for critical care services (99291) provided on September 23, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for magnetic resonance imaging (MRI) scan provided on September 7, 
2022. 
 
You asked the Plan to pay for the MRI. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says that the services denied correctly as you do not meet the 
clinical requirements to be approved. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the MRI by a contract provider. The file does not show that the Plan provided notice that 
the MRI would not be covered. Under Medicare rules, this means the MRI is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for magnetic resonance imaging (MRI) scan provided on 
September 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing meets criteria for coverage. 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 June 22, 2022.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 visits. We decided that the Plan does not have to pre-approve 34 
visits.  
 You asked the Plan to pre-approve 36 additional occupational therapy visits.. You say that this is medically 
necessary. The Plan says that an additional 36 occupational therapy visits are not medically necessary. 
 
We decided that the Plan has to pre-approve 2 visits.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 for the visits. Our reviewer says that two additional 
visits (out of the requested 36) to review instruction on a home exercise program is reasonable and necessary. 
The specialized skill, knowledge and judgment of a qualified therapist is reasonable for 2 additional visits to 
establish and review a home exercise program with the patient. 
 
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 visits have been met. Therefore, we decided that the Plan has to pre-approve 
2 visits.  
 
We also decided that the Plan does not have to pre-approve 34 visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 for these visits. Our reviewer says that 34 out of 36 
additional requested therapy visits is generally not accepted as specific and effective therapy for the patient's 
condition. The patient has had prior extensive therapy and the documentation does not reveal that the patient 
requires the unique skills of a professional therapist to provide treatment safely and effectively, that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist for 34 of the 36 requested visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 34 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 34 visits. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes L1686 and L2624 billed for October 20, 
2022. 
 
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 billed supply code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed supplies. Therefore, we decided that the Plan does not have to pay for procedure codes L1686 and L2624 billed 
for October 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 4, 2022, to July 
3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the 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 for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. 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 4, 2022, to July 3, 
2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 28, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology, in situ hybridization (eg, FISH), urinary 
tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (88120) provided on 
August 3, 2022. 
 
You asked the Plan to pay for the cytopathology. You say that this testing should be covered. The Plan denied 
your request. The Plan says the services are not authorized because code 88120 is not a Medicare benefit for 
the enrollee diagnosis as listed on the claim and is done for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that this assay is performed on urine specimens from 
persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma 
and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. 
 
We looked at the file and Medicare rules. The records show the requested service was billed with a diagnosis of 
unspecified symptoms and signs involving the genitourinary system (R39.9). This is not a covered diagnosis 
for the requested service. Based on this information, we decided that Medicare rules for coverage of the 
cytopathology have not been met. Therefore, we decided that the Plan does not have to pay for the 
cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 
molecular probes, each specimen; manual (88120) provided on August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on July 26, 
2022. 
 
You asked the Plan to pay for the CXbladder detect test. You say that this service was medically necessary and 
is covered under Medicare. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXbladder detect test have not been met. Therefore, we 
decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that the CPT codes billed are included in the dialysis rate. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the requested procedure is not medically necessary at this time. 
 
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 a left heart catheterization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is the medical appropriateness and necessity for performance of 
cardiac catheterization. The medical records indicate continued chest pains since previous catheterization and 
PCI in July 2019, with subsequent cardiac catheterization showing patent stent and multiple radionuclide stress 
tests, most recently February 2023, showing no evidence of ischemia.  Guidelines do not support a need for 
repeat cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be 
considered medically appropriate and necessary in this enrollee's 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 a left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with 
left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 
(93458).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 24, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says Medicare plans 
no longer cover refraction only. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on October 24, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for methadone provided on September 19, 2022. 
 
You asked the Plan to pay for methadone. You say that the Plan did not have all the necessary information to 
process your claims correctly. The Plan denied your request. The Plan says that the claim was billed naming 
the rendering provider, which violates the previously stated policies. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says that coverage for opioid treatment program services is only 
available when provided by a facility such as a freestanding opioid treatment program facility. The claim 
supports that the service is being billed by such a freestanding opioid treatment program facility. Though a 
physician is noted as the rendering provider, payment is being made to the opioid treatment program for the 
services, as is required by the rules. We find that the Plan has not substantiated the denial of payment for these 
services. Therefore, we decided that the Plan has to pay for methadone provided on September 19, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on March 4, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the bill was sent to the wrong primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made three 
attempts to call the member and the Plan has directed the provider to bill to the correct primary insurer. As the 
secondary insurer, the Plan cannot be held responsible for the emergency department visit until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on February 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 Current Procedural Terminology (CPT) code 99152 (1 Units) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found there is insufficient documentation 
of a separate anesthesia provider which is required to bill separately. Therefore, the bill for sedation is not 
supported. 
 
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 moderate sedation services (procedure code 99152) rendered on February 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 9, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim denied as a duplicate in error. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 9, 2022.