Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services to optimize 
functional mobility and increased independence with activities of daily living (ADLs). The Plan denied your 
request. The Plan says the requested IRF admission is not medically necessary. 
 
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 enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly, to regain or maintain their functional status.   
 
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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel provided on 
June 8, 2022, billed with codes 87798, 87150, 87481, 87801, 87640, 87500, 87653 and 87651. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing 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 guidelines. The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel have not been met. Specifically, the records show that this was a single panel 
which was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to 
pay for the urine PCR (polymerase chain reaction) panel provided on June 8, 2022, billed with codes 87798, 
87150, 87481, 87801, 87640, 87500, 87653 and 87651.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve an EGD. You say that your doctor requested to do a follow up endoscopy 
due to pre-cancerous finding and bleeding in esophagus. The Plan denied your request. The Plan says given the 
lack of supportive documentation, this EGD is denied. The Plan also says this EGD is denied as there is no 
indication of length of potential Barrett's segment, there is no submitted confirmed pathology report showing 
Barrett's, and there is a close follow up EGD report from December 2020 that makes no mention of any 
Barrett's. 
 
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 an EGD. Our reviewer says that an 
EGD is not considered medically reasonable and necessary in this case. Our physician reviewer found short-
segment Barrett's is appropriately re-surveilled by EGD at a 5-year interval. Our reviewer found that the 
requested 28-month interval is too short, and not medically reasonable nor necessary based on reviewed 
documentation as supplied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an esophagogastroduodenoscopy (EGD) (43235).
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 enrollee requires inpatient rehab that cannot be 
accomplished at a lower level of care. The Plan denied your request. The Plan says the services the enrollee 
needs can be provided safely in another setting such as a skilled nursing facility. 
 
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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that they 
would meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can receive further 
services at a lower level of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99152, 99153) provided on October 6, 2022. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that the OPPS 
recognizes that CPT code 99153 is a PE only code and that PE are not payable to the physician for services 
provided in the facility setting. 
 
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 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 use of code 99152 is 
not supported by the records provided. Our reviewer found that the documentation does not mention the 
presence of a trained independent observer that monitored the patient for the duration of the procedure. This is 
a required component of CPT 99152. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99152 have not been met. 
 
We also find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to 
the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan 
does not have to pay for the services (99152, 99153) provided on October 6, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2046 billed for date of service September 1, 
2022, to September 27, 2022. 
 
You asked the Plan to pay for procedure code T2046. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 T2046 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2046 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T2046 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2046 billed for date of service September 1, 2022, to September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) provided on April 25, 2022. 
 
You asked the Plan to pay for drug testing G0482. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the ordering physician did not request testing of this number of drug 
classes. 
 The Plan must follow Medicare rules. Medicare rules say that lab tests must be specifically ordered by the 
enrollees treating physician.  
 
We looked at the file and Medicare rules. The record does not show that drug testing G0482 was ordered by the 
enrollees treating physician. Specifically, the lab order form only requested testing for marijuana and 
gabapentin which would constitute 2 drug classes. Code G0482 represents 15 to 21 drug classes. Based on this 
information, we decided that Medicare rules for coverage of drug testing G0482 have not been met. Therefore, 
we decided that the Plan does not have to pay for drug testing (G0482) provided on April 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9328) and baclofen (J0475) 
provided on February 1, 2022 to May 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home infusion therapy and baclofen. You say that you would like these 
claims to be reconsidered for payment. The Plan denied your request. The Plan says the enrollee's plan 
excludes coverage for these OON services.  
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 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 home infusion therapy (S9328) and baclofen 
(J0475) provided on February 1, 2022 to May 6, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 services have been met. The 
submitted documentation does not contain medical records for the date of service in question. Therefore, we 
decided that the Plan does not have to pay for the services provided on September 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient psychiatric admission provided on September 
27, 2022, to October 14, 2022. 
 
You asked the Plan to pay for an inpatient psychiatric admission. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says from September 27, 2022, and forward an inpatient 
stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 an inpatient psychiatric admission. Our 
reviewer says that an inpatient psychiatric admission was not medically necessary. Our physician reviewer 
found the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond 
the date in question of September 27, 2022 forward, and could have been treated in a lesser restrictive setting as 
he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not 
showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to 
safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pay for an inpatient psychiatric admission provided on September 27, 2022, to 
October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services with an out-of-network (OON) 
vascular surgeon. 
 
You asked the Plan to pre-approve medical services with an OON vascular surgeon. You say that the enrollee 
was referred to the OON vascular surgeon for a possible bypass of his right lower extremity due to an occluded 
right common femoral artery. You say that since the enrollee comes to see another doctor in Opelika, it would be more beneficial for him to see the vascular surgeon in that same location. The appellant says that the 
network provider the enrollee was referred to is more than 60 miles from their home. The appellant says that it 
is helpful when a patient's doctors are in the same area and can communicate with each other and help as 
needed. The Plan denied your request. The Plan says medically necessary care is available 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. Medicare rules 
also say that plans must make care accessible to enrollees. According to Medicare rules, care is considered 
accessible to an enrollee if contract providers are available within reasonable distance and travel time from the 
enrollees home. 
 
The provider is a non-contract provider. We were able to confirm that the Plan has contracted vascular 
surgeons located within reasonable distance and travel time from your home who can provide the care needed. 
Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the 
Plan does not have to pre-approve medical services with an out-of-network (OON) vascular surgeon.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasonic guidance for a biopsy billed with code 76942 
for October 13, 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 services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that services with status indicator N are paid under the 
OPPS, but their payment is packaged into payment for a separately paid service. 
 
We looked at the file and Medicare rules. Billed procedure code 76942 has an OPPS status indicator of N. 
Payment for this code is included in the payment for billed code 64415. Therefore, we decided that the Plan 
does not have to pay for the ultrasonic guidance for a biopsy billed with code 76942 for October 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient care provided from October 30, 2022, to October 31, 
2022. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says that the enrollee 
was admitted within the past 30 days. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 care. Our reviewer says that the 
requested inpatient care was medically reasonable and necessary. Our physician reviewer found that the 
enrollee was brought to the emergency department on October 30, 2022, with increased shortness of breath. Per 
EMS, her O2 saturation was in the 70s on 3L oxygen. She was evaluated and started on BiPAP. She was 
admitted to the intensive care unit. Her condition stabilized and improved, and she was discharged home on 
October 31, 2022. The readmission was medically necessary and was not the result of a premature discharge 
from the same hospital.  
 
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 inpatient care have been met. Therefore, we decided that the Plan has to pay 
for the inpatient care provided from October 30, 2022, to October 31, 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: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on August 28, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that your facility is enrolled with 
Medicare, and you provided the Medicare enrollment letter. The Plan denied your request. The Plan says that 
Medicare does not cover services that are not performed by a Medicare-certified provider. 
 
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. Specifically, the Plan has not provided a rule to substantiate their denial. The 
Medicare letter that has been provided is proof that this facility is approved to participate in Medicare during 
the COVID-19 Public Health Emergency. Therefore, we decided that the Plan has to pay for an emergency 
department visit provided on August 28, 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: Home Health
Decision: Favorable

 
We decided that the Plan has to make additional payment for the home health services provided from 
November 5, 2022, to December 4, 2022. 
 
You asked the Plan to make additional payment for the home health services. You say that the records support 
that this was medically necessary. The Plan denied your request. The Plan says that this cannot be considered 
an institutional admission source as the hospital stay prior to admission was outpatient. 
 
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's rationale is that since the hospital stay prior to the home health 
admission was outpatient; however, the Plan failed to include any evidence in the file to support this. Without a 
copy of the claim for the hospital stay, it cannot be determined that the code billed for this episode of care is 
incorrect. As such, the reduction of payment is not supported. Therefore, we decided that the Plan has to make 
additional payment for the home health services provided from November 5, 2022, to December 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.