Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93005 billed for date of service August 13, 2022. 
 
You asked the Plan to pay for code 93305. You say that this claim should be paid at 90% of billed charges. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. 
 
In this case, the code in dispute (93005) is an STV-packaged service because it has a status indicator of Q1 in 
Addendum B- Outpatient Prospective Payment System (OPPS).  Code 93005 was billed on the same claim as 
code 99285. Code 99285 has a status indicator of V.  This means that code 93005 is not separately payable in this scenario. 
.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 93305 have not been met. Therefore, we decided that the Plan does not have to pay for code 
93005 billed for date of service August 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service September 
24, 2022. 
 
You asked the Plan to pay for procedure code 99283. You say that this was an appropriately identified separate 
service. The Plan denied your request. The Plan says payment for code 99283 is bundled into payment for code 
99284. 
 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 99283 
is a column II code to column I code 99284. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99283 billed for date of service September 24, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (99336) provided on July 5, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 home health services (99336) provided on July 5, 
2022, by an out-of-network (OON) provider.
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 surgeon suggested the enrollee has inpatient 
rehabilitation, following a complete knee replacement the level of care needed cannot be obtained through a 
skilled nursing facility. The Plan denied your request. The Plan says the records do not show that the enrollee 
has complex rehabilitation needs requiring frequent evaluation by a rehabilitation doctor. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (95913) provided on August 10, 
2022. 
 
You asked the Plan to pay for the nerve conduction studies. You say that the medical documentation supports 
the service and procedure performed. You also say that you would like the denied claim to be adjusted 
accordingly. The Plan denied your request. The Plan says charges for or in connection with services or supplies 
that are considered to be experimental or investigational are excluded from coverage under the enrollee's plan. 
 
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 pay for the nerve conduction studies. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has sensorineural polyneuropathy following 
chemotherapy. The provided records demonstrate that the enrollee has a normal neurologic examination. Our 
reviewer found that the provided records are insufficient to demonstrate the medical necessity of the requested 
service or how the results would alter management.  The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. Our reviewer also found 
that the elements of the coverage criteria are not satisfied, and 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 nerve conduction studies have not been met. Therefore, we decided that the 
Plan does not have to pay for the nerve conduction studies (95913) provided on August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 27, 
2022, to March 3, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the decision to admit the enrollee 
for treatment of their hand numbness, hypotension, and hypovolemia was appropriate. The Plan denied your 
request. The Plan says more details are needed to determine if the specific circumstances of the enrollee's 
hospitalization meet the criteria for coverage. 
 
 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found in the emergency department, the enrollee was able to move their right 
arm, but had paresthesias and pain. Our physician reviewer found that soon after admission symptoms 
improved further, and vitals remained stable. The treating physicians documented that they thought the 
symptoms were not related to transient ischaemic attack but rather related to musculoskeletal in nature 
following recent snow shoveling. Our physician reviewer also found that based on the low severity and low 
complexity of this presentation and initial workup, it was not expected that the enrollee would require hospital 
services that would likely cross 2 midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from February 27, 2022, to March 
3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 3, 2022, 
to May 10, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that this was an emergency admission, 
and you believe the denial should be overturned. The Plan denied your request. The Plan says the enrollee did 
not meet criteria for inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found based on the low complexity and low severity of this presentation and post-
surgical status of this enrollee, it was not expected that they would require hospital care that would likely cross 
2 midnights. Our reviewer also found that observation status would have been more appropriate. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from May 3, 2022, to May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 22, 2022, billed with 
codes 81432, 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 22, 2022, billed with codes 81432, 81433.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires around the clock assistance 
until they gain their independence back. The Plan denied your request. The Plan says the services the enrollee 
requires can safely be received at a different setting such as home with home health, in residential care, or 
home with close follow-up with your doctor. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The 
enrollee does not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 have switched to oral medications and is now 
ready to be transferred to the rehabilitation center by ambulance. You say you want to build strength with 
physical therapy in order to get back to your daily activities. The Plan denied your request. The Plan says the 
IRF care is not medically necessary, and your needs can be met at a lower level of care 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 you were admitted for congestive heart failure and pulmonary fibrosis. Your medical 
problems are stable, and there are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. 
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting IPR so the enrollee can regain 
maximum function. The Plan denied your request. The Plan says IRF is not medical necessary. The enrollee's 
needs can be managed at a lower level of care, such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitors (CGM) (K0553) provided on 
August 27, 2022. 
 
You asked the Plan to pay for the CGM. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the date of service billed on this claim does not match the 
shipping date or the date or delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the shipping date of this item was August 19, 2022, and the delivery date was August 23, 2022. Therefore, 
the date of service billed on this claim, August 27, 2022, does not meet Medicare rules. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for a continuous glucose monitors (CGM) (K0553) provided on August 27, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9343 billed for date of service September 9, 
2022 to September 14, 2022. 
 
You asked the Plan to pay for procedure code S9343. You say that you disagree with the denial. 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 S9343 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9343 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9343 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9343 billed for date of service September 9, 2022 to September 14, 2022.
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 long term acute care is medically 
necessary. The Plan denied your request. The Plan says member does not meet all requirements for an LTACH 
admission. 
 
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 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. The health 
plan has approved ongoing care in the current acute care 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 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sauna bath. 
 
You asked the Plan to pre-approve these services. You say that you need the bath to soak your body and ease 
aches. The Plan denied your request. The Plan says the item does not serve a purpose that is primarily medical 
in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a sauna bath.
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 had a stroke, and your physician believes that 
you need to be an IRF for your best chance at a full recovery. The Plan denied your request. The Plan says the 
IRF care is not medically necessary, and your needs can be met at a lower level of care such as a home with 
supervision and home health services, an assisted living facility with home health services, or a long-term care 
facility with part-time skilled services. 
 
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 were admitted for stroke and urinary tract infection. Your medical problems are 
stable, and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. 
 
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.