Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laser skin treatment provided on October 20, 2021, billed 
with code 96920 
 
You asked the Plan to pay for the laser treatment as billed. You say that this is a covered procedure, and you 
were told authorization was not required. The Plan denied your request. The Plan says this was not billed 
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 96920 is laser treatment for inflammatory skin disease 
(psoriasis); total area less than 250 sq cm. 
 
We find that CPT code 96920 is not supported in the medical record. Specifically, neither the diagnosis 
reported on the claim nor the records submitted support that this treatment was used for psoriasis. As the code 
definition specifies psoriasis, the code is not supported. Based on this information, we decided that Medicare 
rules for coverage of the laser treatment as billed have not been met. Therefore, we decided that the Plan does 
not have to pay for the laser skin treatment provided on October 20, 2021, billed with code 96920
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) genetic testing panel 
provided on October 15, 2021. 
 
You asked the Plan to pay for the F1CDx panel. You say that this is an FDA-approved test and should be 
covered by Medicare. The Plan denied your request. The Plan says this is a screening test that was not billed 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that FDA-approved NGS testing is covered for 
enrollees who meet the criteria listed in the Medicare rules section. 
 
In this case, very limited clinical documentation for this enrollee was included in the file. Though we agree that 
F1CDx is a covered test under Medicare, there is not sufficient documentation that the enrollee has advanced 
stage III or IV cancer or that further treatment is desired. These items must be documented to support coverage. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) genetic testing 
panel provided on October 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 25, 
2021. 
 
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 provider did not bill as required by Medicare coding regulations. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on June 9, 2021. 
 
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 were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of malignant 
neoplasm of bladder (invasive high-grade urothelial carcinoma). Ureters and lymph nodes negative for tumor. 
The documentation does not support that the enrollee has recurrent, relapsed, refractory, metastatic, or 
advanced stage III or IV cancer, and has decided to seek further cancer treatment (e.g., therapeutic 
chemotherapy). The testing was therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the FoundationOne CDx testing rendered on June 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
March 13, 2022. 
 
You asked the Plan to pre-approve the continued SNF care. You say that you are not ready to leave the facility 
at this time. The Plan denied your request. The Plan says you no longer require daily skilled services to 
maintain your condition. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 79-year-old 
woman with a history of brain tumor, hypertension, urinary tract infection, pneumonia, essential tremor, and 
morbid obesity, who has been receiving SNF services. The enrollee was admitted to the hospital on 2/21/22.  
No required skilled nursing services are identified. The documentation supports that the enrollee has plateaued 
in therapy. Daily skilled therapy is no longer required. The documentation does not support that continued 
skilled therapy services are medically reasonable and necessary on a "daily basis" on an inpatient basis, in a 
skilled nursing facility setting. 
 
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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond March 13, 2022.
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Your rehab needs can be 
met safely at a lower intensity and alternate setting such as in a skilled nursing facility or in-home therapies. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet 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 enrollee appears to still not be stable and requires additional short-term acute care 
services that can safely be administered at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to LTACH is not 
medically necessary as it would not be clinically advantageous and as the enrollee does not have a stable 
feeding source. 
 
 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treprostinil, inhalation solution (J7686). 
 
You asked the Plan to pre-approve treprostinil, inhalation solution (J7686). You say that the medication is 
necessary, and you have not received a previous denial. The Plan denied your request. The Plan says that the 
request for Tyvaso is non-covered due to a diagnosis of pulmonary hypertension associated with interstitial 
lung disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 treprostinil, inhalation solution (J7686). 
Our reviewer says that Tyvaso is medically necessary, and the enrollee meets the Medicare criteria for 
coverage. Our physician reviewer found that the enrollee has pulmonary arterial hypertension due to mixed 
connective tissue disease and interstitial lung disease. Tyvaso labelled indications include pulmonary arterial 
hypertension associated with interstitial lung disease. The Medicare criteria for coverage has been met due to 
progression of disease, the mean pulmonary artery pressure >25 and calcium blockers considered ruled out. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treprostinil, inhalation solution (J7686) have been met. Therefore, we decided 
that the Plan has to pre-approve treprostinil, inhalation solution (J7686).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging 
 
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 this service should not be unbundled. 
 
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 72192 is a column II code to column I code 74150. 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 imaging
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that it is felt that this is medically necessary. The 
Plan denied your request. The Plan says ventilators are not covered for this enrollee's condition. 
 
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 ventilator. Our reviewer says that 
the criteria for coverage of the ventilator are not met. Our physician reviewer found the patient has severe 
obesity with obstructive sleep apnea. She has used continuous positive airway pressure (CPAP) but refused this 
treatment in the hospital; therefore, it seems likely that the patient would not tolerate the interface involved 
with noninvasive ventilation. The patient does not have a Medicare-covered diagnosis for this device.  
Medicare does not cover a home ventilator when used as bilevel PAP (BiPAP).  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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. The 
enrollee's rehab needs can be met safely at a lower intensity and alternate setting such as in a skilled nursing 
facility or in-home therapies. 
 
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 it is felt that IRF care would be the best option. The 
Plan denied your request. The Plan says IRF criteria are not 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 the enrollee is admitted to an acute hospital on 2/3/22 with colon cancer and acute 
kidney injury. He had Atrial fibrillation and developed a stage II sacral decubitus ulcer.  He underwent right hemi colectomy Ileostomy and small bowel resection on 2/26/22. He also underwent 
Cystoscopy and balloon urethroplasty with placement of Foley catheter.  
 
The enrollee is medically stable and does not need PM&R physician supervision 3 times per week (at a 
minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. At 
the current functional level of maximal assistance, the enrollee does not need intensive therapies, consisting of 
at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in 
an IRF. IRF admission is not medically necessary based on lack of medical complexity and lack of acute rehab 
nursing needs. 
 
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 in addition to basic services (99053) provided on 
August 10, 2021. 
 
You asked the Plan to pay for the services in addition to basic services (99053). You say that the patient was 
seen twice on the same date of service at two different times or by two different providers. You say that notes 
from both services are included, and the claim should be reprocessed accordingly for payment. The Plan denied 
your request. The Plan says CPT code 99285 will be allowed, and CPT code 99053 remains denied as it is not 
paid separately. 
 
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 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
 
We find that CPT code 99053 is not supported in the medical record. Specifically, CPT code 99053 has a status 
indicator of B. This means that CPT code 99053 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the services in addition to basic services 
(99053) have not been met. Therefore, we decided that the Plan does not have to pay for the services in 
addition to basic services (99053) provided on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on March 17, 2021. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that providers/suppliers have an obligation, under law, to 
conform to the requirements of the Medicare program. 
 
We looked at the file and Medicare rules. There is no documentation to support that the services were 
performed for the date of service at issue. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
telehealth services rendered on March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 28, 2021. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that panels with more than 5 respiratory pathogens 
performed in the Part B outpatient setting are considered not medically necessary. 
 
We looked at the file and Medicare rules. The file shows that more than five pathogens were tested. Therefore, 
we decided that the Plan does not have to pay for the laboratory services rendered on September 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home therapy (S9343) provided from March 14, 2021, 
through March 25, 2021. 
 
You asked the Plan to pay for the home therapy (S9343). You say that only $576.60 of the charges were paid 
and the remaining charges were never reviewed. You say that the corrected claim and submitted charges should 
be corrected. The Plan denied your request. The Plan says CPT code S9343 is invalid for Medicare billing 
purposes. 
 
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 S9343 is home therapy; enteral nutrition via bolus; 
administrative services, professional pharmacy services, care coordination, and all necessary supplies and 
equipment (enteral formula and nursing visits coded separately), per diem.  We find that CPT code S9343 is not supported in the medical record. Specifically, CPT code S9343 has a status 
indicator of I. This means that CPT code S9343 is not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of the home therapy (S9343) have not been met. Therefore, we 
decided that the Plan does not have to pay for the home therapy (S9343) provided from March 14, 2021, 
through March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autograft for spine surgery (20936) provided on June 2, 
2021. 
 
You asked the Plan to pay for the autograft for spine surgery (20936). You say that the surgery should be 
processed for payment. The Plan denied your request. The Plan says bundled services are not eligible for 
separate reimbursement. 
 
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 20936 is autograft for spine surgery only (includes 
harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List 
separately in addition to code for primary procedure).  
We find that CPT code 20936 is not supported in the medical record. Specifically, CPT code 20936 has a status 
indicator of B. This means that CPT code 20936 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the autograft for spine surgery (20936) have 
not been met. Therefore, we decided that the Plan does not have to pay for the autograft for spine surgery 
(20936) provided on June 2, 2021.