Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 provided records and letter of medical necessity do not explain what care services 
the LTACH will provide that are not available in the enrollee's present hospital setting. Continued care in the 
short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such 
as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided on March 12, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you want the Plan to pay for the service. The Plan 
denied your request. The Plan says the claim did not contain a Dex-Z code unique identifier which is required 
by Medicare.  
The Plan must follow Medicare rules. Medicare rules say that tests approved through the MolDX program must 
be billed with the unique test identifier.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, tests approved through the MolDX program must 
be billed with the unique test identifier, and this claim does not include that identifier. Therefore, we decided 
that the Plan does not have to pay for genetic testing (0037U) provided on March 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the enrollee 
to receive the LTACH services. The Plan denied your request. The Plan says the records do not show that it is 
not safe for the enrollee to leave the hospital. The enrollee's current care includes management breathing, 
pneumonia, and bacteremia. When their care is done and it's safe for them to be discharged, they can safely 
receive this care in another setting, such a skilled nursing facility or at home with home health services or 
outpatient setting if appropriate. 
 
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 that 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. 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 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 the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug test(s) provided on January 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug test(s). You say that you would like to request reconsideration of the denied 
claim and that the services provided were medically necessary. The Plan denied your request. The Plan says the 
provider is out-of-network and authorization is required prior to an out-of-network visit. 
 
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 drug test(s) provided on January 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10035 billed for date of service January 6, 
2022. 
 
You asked the Plan to pay for procedure code 10035. You say that you have provided records to support the 
services at issue. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 10035 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 10035 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 10035 billed for date of service January 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an integrated biopsychosocial assessment (code 90791) provided on 
March 24, 2022. 
 
You asked the Plan to pay for an integrated biopsychosocial assessment. You say that diagnosis code F43.22 is 
a payable code and is a medically necessary for code 90791 per CMS article A57520. The Plan denied your 
request. The Plan says that code 90791 is not appropriate for primary diagnoses code F43.22. A corrected claim 
is needed with a valid service for this diagnosis for processing. 
 
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 has not provided us with the codes that the Plan say the provider needs 
to rebilled with, and the Plan has not provided us with a rule to support the denial. Therefore, we decided that 
the Plan has to pay for an integrated biopsychosocial assessment (code 90791) provided on March 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says procedure code 99140 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and 
management of a new patient (99204) provided on April 20, 2022. 
 
You asked the Plan to pay for the physician service. You say that the claim is the only new patient claim under 
the Nephrology specialty. You also say that the claim should be processed for payment. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting 
problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient 
and/or family. 
 
We find that CPT code 99204 is not supported in the record. Specifically, the documentation submitted 
indicates that this enrollee previously received professional services from this physician and billing group. 
Based on this information, we decided that Medicare rules for coverage of the domiciliary visit have not been 
met. Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit for the 
evaluation and management of a new patient (99204) provided on April 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injections (CPT code J7324 x6). 
 
You asked the Plan to pre-approve the injections. You say that the services are necessary. The Plan denied your 
request. The Plan says there is no report that the enrollee improved from the last injection series that they 
received. The Plan states there is no report that they are still having knee pain; therefore, this request has not 
been approved at this time. 
 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 injections. Our physician reviewer 
found the record indicates that the enrollee has osteoarthritis of the knees. The record indicates that the enrollee 
underwent viscosupplementation injections in March 2022. The record provided does not indicate the results of 
the previous injection series. The elements of the coverage criteria are not satisfied. The requested service is 
not 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orthovisc injections (CPT code J7324 x6).
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 need IRF care. The Plan denied your request. 
The Plan says therapy can be received at an alternate 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 hip fractures do not require intensive rehabilitation and do not require frequent 
physiatry oversight to restore function. You have an uncomplicated fracture. You need pain management and support while weight bearing as tolerated. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical-necessity rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require the intensity of services provided at an IRF. Specifically, you 
are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  
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: 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 OHS. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
AVAPS 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 enrollee has obesity-
hypoventilation syndrome (OHS) and OSA, with pulmonary hypertension, requiring repeated hospitalizations. 
The appropriate treatment is BiPAP, with or without AVAPS. There is no documented failure of BiPAP as an 
outpatient. Medicare does not cover a home ventilator for OHS, or when used as BiPAP. The enrollee may 
benefit from a PAP titration study. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a femoral nerve block (64447). 
 
You asked the Plan to pre-approve the nerve block. You say that the enrollee would benefit from this. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the nerve block. Our reviewer says that 
the requested nerve block is not considered medically reasonable and necessary in this case. Our physician 
reviewer found interventional approaches, such as peripheral nerve injections may provide short-term 
analgesia. The reviewer found however, that the evidence is limited for significant improvements in long-term 
outcomes. Therefore, the review found that the femoral nerve block is not medically reasonable or 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a femoral nerve block (64447).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the requested 
device have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested HFCWOD is not medically reasonable and necessary.  Our physician reviewer found this patient has severe COPD and recent pneumonia. There is no diagnosis of 
cystic fibrosis, bronchiectasis, or neuromuscular disease. There is insufficient evidence that HFCWOD is 
effective in the treatment of COPD, and Medicare does not cover it for that diagnosis. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on April 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that the enrollee was seen in the absence of their 
primary care physician. You say that the enrollee required medication refills. You also say that the service 
should be covered. The Plan denied your request. The Plan says the claim processed correctly. 
 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214) provided on April 26, 2022, by an out-of-
network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on September 23, 2021. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says Licensed 
Professional Counselors are not able to be reimbursed by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on 
September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed. 
 
You asked the Plan to pre-approve a hospital bed. You say that your bed no longer works. The Plan denied 
your request. The Plan says you have received a bed within the past 5 years. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a hospital bed. There is no documentation that your current bed has damage 
beyond repair. Based on this information, we decided that the Medicare rules for coverage have not been met.  
Therefore, we decided that the Plan does not have to pre-approve a hospital bed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four units of procedure code 76642 billed for date of service 
May 23, 2022. 
 You asked the Plan to pay for procedure code 76642. You say that these services were reported correctly. 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 cannot be paid when the MAI value is 2. 
 
In this case, the MUE for CPT code 76642 is two (2). The MAI value for this code is 2. You billed four (4) 
units of this code (76642-LT x2, 76642-RT x2), exceeding the MUE. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76642 have not been met. Therefore, we decided that the 
Plan does not have to pay for four units of procedure code 76642 billed for date of service May 23, 2022.