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

 
We decided that the Plan does not have to pay for the Medical Nutrition Therapy (MNT) services (97802) 
provided on November 2, 2021. You asked the Plan to pay for MNT services. You say that this claim was billed correctly, and these services 
were necessary and appropriate. The Plan denied your request. The Plan says that these services were not 
provided by an appropriate provider type for an appropriate condition as defined by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medical Nutrition Therapy services are covered 
when they are furnished by a registered dietitian or nutrition professional meeting certain requirements, and the 
services are provided to a patient with diabetes or renal disease when a referral is provided by a physician.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of MNT services have not been met. Specifically, the diagnosis billed with this claim is prediabetes 
(R73.03) and is not diabetes or renal disease. In addition, the rendering provider is shown to specialize in 
internal medicine endocrinology, diabetes and metabolism. Therefore, we decided that the Plan does not have 
to pay for the Medical Nutrition Therapy (MNT) services (97802) provided on November 2, 2021.
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. 
 
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 you appear to be improving and should only require short-term additional acute care 
services that can safely be administered at the current facility. There are no services at the LTACH that you 
require that are not already available and covered at the current facility. Transfer to LTACH will be considered 
not medically necessary as it would not be clinically advantageous at this time compared to completing 
treatment at the current 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare criteria for coverage. 
 
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's rehabilitation needs can be safely met in an alternate and lower 
intensity setting such as in an SNF. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drug test (CPT code G0483) provided on September 
20, 2021. 
 You asked the Plan to pre-approve the drug test. You say that the drug screen provides valuable information for 
physicians to use in determining the appropriate medication for the treatment of the patient. The Plan denied 
your request. The Plan says the request for definitive urine drug testing of this number of drug classes is 
considered not medically reasonable and 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 drug test. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review has determined that the request for definitive urine drug testing of this number of 
drug classes is considered not medically reasonable and 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 drug test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the drug test (CPT code G0483) provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for radiofrequency ablation, nerves innervating the sacroiliac joint (CPT 
code 64625LT) provided on August 10, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that radiofrequency ablation used for sacroiliac joint pain is considered not medically 
necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
 
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. It appears that the plans contracted delegate was provided the records for this 
admission and has failed to forward them to support the decision to deny based on no medical necessity. 
Therefore, we decided that the Plan has to pay for radiofrequency ablation, nerves innervating the sacroiliac 
joint (CPT code 64625LT) provided on August 10, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81406, 81405, and 81404) provided 
on August 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81406, 81405, and 81404) provided on August 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on July 15, 2021, 
to August 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that that the inpatient level of care was 
medically necessary. The Plan denied your request. The Plan says the request does not show the member had 
signs or symptoms or needed treatments requiring an inpatient hospital stay. 
 
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 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 the provided records did not suggest the member required 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 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 on July 15, 2021, to August 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 10, 2022. 
 
You asked the Plan to pre-approve SNF care after March 10, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 after March 10, 2022. Our 
reviewer says that continued daily skilled services are not necessary. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF 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 after March 10, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary compressed oxygen system (E0424). 
 
You asked the Plan to pre-approve the stationary compressed oxygen system. You say that the stationary 
compressed oxygen system is medically necessary. The Plan denied your request. The Plan says coverage rules 
have not been met. 
 
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 the plan has already pre-approved an oxygen concentrator (E1390). The oxygen 
concentrator serves the same purpose as a stationary compressed oxygen system. Therefore, we decided that 
the Plan does not have to pre-approve a stationary compressed oxygen system (E0424).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided February 12, 
2021. 
 
You asked the Plan to pay for the office visit. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says there is evidence of misrepresented services. 
 
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 outpatient office visit (99202) 
provided February 12, 2021. have been met. there is no evidence of an established relationship between the 
enrollee and the physician. The Plan had also made multiple attempts to obtain additional records from the 
provider without success. Therefore, we decided that the Plan does not have to pay for the outpatient office 
visit (99202) provided February 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 19 to March 
20, 2019. 
 You asked the Plan to pay for inpatient hospital services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says DRG 246 is not supported by the 
medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 246, "percutaneous cardiovascular procedures 
with drug-eluting stent," and secondary diagnosis code I50.23, "Acute on chronic systolic (congestive) heart 
failure." 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 inpatient hospital services. Our 
reviewer says that the provided medical records do not support DRG 246 and secondary diagnosis I50.23. Our 
physician reviewer found that the provider assigned secondary diagnosis code I50.23 (Acute on chronic 
systolic (congestive) heart failure), which was found to be clinically unsupported. The medical record did not 
provide clinical evidence to support the diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 19 to March 20, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided from  
August 19, 2021, through September 3, 2021. 
 
You asked the Plan to pay for skilled nursing facility services. You say that the enrollee was discharged to the 
hospital due to a fall and readmitted requiring rehabilitation under a diagnosis unrelated to her hospice 
condition. The Plan denied your request. The Plan says Original Medicare would be responsible for payment 
of all Medicare covered services related or unrelated to the members terminal condition. The Medicare 
hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to 
the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the 
month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for skilled nursing facility services provided from  
August 19, 2021, through September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 You asked the Plan to pre-approve the requested services. You say that the enrollee has severe and intractable 
pain. The Plan denied your request. The Plan says there is no documentation of a response to previous 
injections. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic neck pain due to cervical central canal and neuroforaminal stenosis 
causing radiculopathy to her right upper extremity. She has been treated with medical therapy including, 
opiates and is status post a cervical epidural steroid injection. The clinical documentation does not include an 
evaluation to substantiate the effectiveness of the injections provided. The medical records provided do not 
include documentation for the conservative treatments that were tried and failed. The review has determined 
that the requested injection 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the motorized scooter (K0800), provided on July 19, 2021. 
 
You asked the Plan to pay for the motorized scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you obtained this is item through a provider who is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the motorized scooter (K0800), provided 
on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 27, 2021. 
 
You asked the Plan to pay for lab test. You say that you were compliant with Medicare regulations for billing 
the date of service and place of service. The Plan denied your request. The Plan says the denial of payment for 
this testing is correct, because the documentation submitted does not support the Place of Service (POS) code 
billed on this claim. The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lab test have not been met. Specifically, this claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on May 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology (88305) provided on September 1, 
2021. 
 
You asked the Plan to pay for the surgical pathology (88305). You say that this service is a proprietary test and 
is now considered standard of care. You say that this service can only be performed by the provider, and this 
should not have been denied as non-covered. The Plan denied your request. The Plan says the denial is upheld 
as the billed procedure code 88305 has a physician Fee Schedule indicator of 1. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, the records indicate that the 
member was an outpatient on the billed date of service. The records also show that the facility has been paid for 
this service. Payment for CPT code 88305 is included in the payment to the facility and is the responsibility of 
the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the 
surgical pathology (88305) have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical pathology (88305) provided on September 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft (20902) and an osteoplasty of facial bones 
(21208) provided on June 3, 2021. 
 
You asked the Plan to pay for a bone graft and an osteoplasty of facial bones. You say that you have provided 
records to support the services billed. The Plan denied your request. The Plan says the billed codes are 
inclusive to another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 a bone graft and an osteoplasty of facial bones. Our reviewer 
says that the billed codes 20902 and 21208 do not meet criteria for reimbursement. Our reviewer found that 
CPT codes 20902 and 21208 would be separately reported if performed in different areas.  In this case, there is one donor area (arm) described. The operative report describes a free osteocutaneous flap 
with microvascular anastomosis in the arm. This is a more comprehensive procedure; therefore, in this case 
CPT codes 20902 and 21208 would be inclusive to CPT code 20969. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bone graft and an osteoplasty of facial bones have not been met. Therefore, 
we decided that the Plan does not have to pay for a bone graft (20902) and an osteoplasty of facial bones 
(21208) provided on June 3, 2021.