Persius/hicric huggingface dataset:
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 it is necessary for the enrollee to go to skilled 
nursing. 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 or home with home health services. 
 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 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 skilled nursing 
facility (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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
August 23, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the decision that Guardant 
Reveal is experimental and investigational and request processing of the claim as in-network since you are the 
only service provider for Guardant Reveal. The Plan denied your request. The Plan says there is no evidence to 
support the referring or ordering provider is treating the enrollee.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The Plan made outreach to the ordering provider indicated on the 
claim who verified that they did not order the genetic testing. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted molecular pathology procedure (81479) provided August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM). 
 
You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor (CGM). You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the items rendered are 
not supported. 
 
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 physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Review of the file shows that no 
documentation was provided to support the supply items rendered. 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 the supply allowance for therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service September 9, 
2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99233 is bundled into payment for code 99223. 
 
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 99233 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99233 billed for date of service September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on July 28, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the anesthesia services provided based on Medicare criteria. Therefore, we decided that the Plan 
has to pay for the anesthesia services provided on July 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided August 3, 
2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim to be 
reconsidered for payment for medical necessity as pneumatic compression devices are a proven treatment for 
deep venous thrombosis. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305, 88313) provided on June 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and were reported 
correctly. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab services 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 lab services (88305, 88313) provided on June 21, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87481, 87651, 87653, 87491, 87496, 87500, 
87529, 87532, 87563, 87591, 87641, 87661, 87798) provided on August 23, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the provided medical records. The Plan denied your request. The Plan says that these services are 
denied. 
 
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 provided no clear reason for denial, and has not 
supported their denial with any citation or evidence. The Plan's denial is not substantiated in this case. 
Therefore, we decided that the Plan has to pay for laboratory services (87481, 87651, 87653, 87491, 87496, 
87500, 87529, 87532, 87563, 87591, 87641, 87661, 87798) provided on August 23, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
August 3, 2021, to August 15, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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 diagnosis code J96.01 - acute respiratory failure 
with hypoxia. 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 hospital 
services at the DRG originally billed. Our reviewer says that the services at issue in this case were not 
supported by the medical records. Our physician reviewer found that the enrollee was treated in the hospital 
following a hip fracture. He was found to be hypoxic (89-91% on room air and was given 1-2L oxygen 
supplementation via NC with benefit. However, the documentation did not reveal any time the patient required 
or used vent or BiPAP support or high flow oxygen supplementation before or after the surgery during this 
hospitalization. Therefore, the criteria for acute respiratory was not met and the diagnosis for such (J96.01) is 
not supported in the documentation or appropriate to be assigned to this admission.   
 
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 to the enrollee from August 3, 2021, to August 15, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0427-RW) billed for date of service July 2, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that these were ET3 ambulance services, and the 
"W" modifier is appropriate in this case. The Plan denied your request. The Plan says that modifier "W" is an 
invalid destination modifier on ambulance claims. 
 
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 A0427-RW is supported in the medical record. Specifically, modifier "W" is an 
appropriate destination modifier for use with ET3 ambulance claims. Based on this information, we decided 
that Medicare rules for coverage of ambulance services have been met. Therefore, we decided that the Plan has 
to pay for ambulance services (A0427-RW) billed for date of service July 2, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight genomic testing (81479) provided September 
14, 2022. 
 You asked the Plan to pay for the genetic testing. You say that this appeal should be approved and paid at the 
established rate of $1,568.64 for Genesight multi-gene testing under CPT code 81479. The Plan denied your 
request. The Plan says the requested genomic testing ordered was not medically reasonable. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee with diagnoses reported as F41.1 - Generalized anxiety 
disorder and F33.8 - Other recurrent depressive disorders. The requested genomic testing ordered on September 
14, 2022, was not medically reasonable and necessary for this enrollee. Less than 3 months earlier, the enrollee 
reported stability on his anxiety medications with excellent improvement in his symptoms. Medical records 
were requested from the ordering provider's office; only the office note from the June 30 visit was provided. 
There is no documentation of an adverse reaction to any type of psychiatric medication, and no explanation 
why genomic testing was believed to be 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the GeneSight genomic testing (81479) provided September 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493 and 64494 billed for date of service 
June 9, 2022. 
 You asked the Plan to pay for procedure codes 64493 and 64494. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64493 and 64494 is 1. The MAI value for this code is 2. You billed 2 units 
of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 64493 and 64494 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 64493 and 64494 billed for date of service June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360, 88377, and 88381 billed for date of 
service February 9, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360, 88377, and 88381. The Plan denied your request. The 
Plan says these codes are included in the facility payment and are not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360, 88377, and 
88381. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360, 
88377, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure code 
88360, 88377, and 88381 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88360, 88377, and 88381 billed for date of service February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 prostate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found prostatic arterial embolization is not medically necessary in this case. 
Prostatic arterial embolization is considered an experimental technique to treat symptomatic benign prostatic 
hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service April 20, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that you disagree with the Plan's 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 S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service April 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 17, 2022, to 
June 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 17, 2022, to June 
15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug coded J3490 provided on September 15, 2022. 
 
You asked the Plan to pay for the drug coded J3490. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service was provided on 
the same date of service as 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image 
guidance (fluoroscopy or CT) including arthrography when performed). This means separate payment cannot 
be made for J3490 as it is included in the global surgery period of the surgery procedure. Based on this 
information, we decided that Medicare rules for coverage of the drug coded J3490 have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug coded J3490 provided on September 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on August 5, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the ordering physicians intent that the testing be performed. Based on this information, we decided 
that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the testing provided on August 5, 2022.