Persius/hicric huggingface dataset:
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 the enrollee meets IRF admission criteria. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 29, 2022, to May 
27, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes G0299, A6219, G0157, & G0151 are not supported in the medical record. Specifically, 
the number of days billed exceeds the 30 days for a single period of care. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided 
that the Plan does not have to pay for home health services provided on March 29, 2022, to May 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an enteric pathogens panel (87324, 87506) provided on 
December 16, 2021. 
 
You asked the Plan to pay for the services. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this testing was not medically 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the limited clinical documentation does not support that the GIP testing provided on 12/16/21 was 
medically reasonable and necessary for the enrollee in this case. C. Difficile toxin was tested separately and 
was negative. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for an enteric pathogens panel (87324, 87506) provided on December 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (97110) provided on October 13, 2021. 
 You asked the Plan to pay for therapeutic services. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported 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 these services not supported in the medical record as billed. Specifically, the documentation 
shows that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a 
Physical Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the 
therapy services were being rendered. The incident-to requirements have not been met in this case. Based on 
this information, we decided that Medicare rules for coverage of therapeutic services have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic services (97110) provided on October 
13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative ultrasonic guidance provided to the enrollee 
on February 8, 2022. 
 
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 Current Procedural Terminology (CPT) code 76998-26 (1 unit) remains not supported. 
 
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 76998 is "Ultrasonic guidance, intraoperative." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative note of 2/8/22 lists 
ultrasound guidance. However, the details of the procedure, findings, and the use of ultrasound are not 
explained. Absent such documentation the reimbursement for the ultrasound guidance is not indicated. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for intraoperative ultrasonic guidance provided to the enrollee on February 8, 2022.
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 enrollee meets LTACH admission 
criteria. The Plan denied your request. The Plan says the request 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (96372) provided on May 31, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 96372 is not supported in the medical record. Specifically, this code has a status 
indicator of Q1. Code 99284 was billed on the same date of service and has a status indicator of "V". CPT 
96372 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician 
services (96372) provided on May 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental for back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Segmental gradient pressure pneumatic appliance, half leg 
(E0673) provided March 10, 2022. 
 
You asked the Plan to pay for the pneumatic appliance. You say that say the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says since the place of service 
is an ambulatory surgical center (24), the segmental gradient pressure pneumatic appliance, half leg is not 
covered. 
 
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 enrollee used the equipment in the facility during and/or after surgery. Payment for this service 
would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery.  Based on this information, we decided that Medicare rules for coverage 
of the pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pay for 
Segmental gradient pressure pneumatic appliance, half leg (E0673) provided March 10, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the chest x-ray (71045) provided on June 21, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the claim denied in error. You say that the documentation 
supports that this service was performed by your provider. The Plan denied your request. The Plan says that 
that there was no documentation to support that the service was performed twice. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the file does not support that a claim for 
this service has already been paid. Based on this information, we decided that Medicare rules for coverage of 
the x-ray have been met. Therefore, we decided that the Plan has to pay for the chest x-ray (71045) provided on 
June 21, 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 SelectMDx testing billed with code 81479-GZ for date of 
service June 10, 2021. 
 
You asked the Plan to pay for SelectMDx testing billed with modifier GZ. You say that this test was necessary 
and was performed by a certified laboratory. The Plan denied your request. The Plan says this service does not 
meet criteria for medical necessity as it was submitted by the provider with the GZ modifier. In addition, this 
test was not pre-approved by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules state that items submitted with a 
GZ modifier shall be denied automatically and will not be subject to complex medical review. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx testing billed with modifier GZ have not been met. Specifically, this service was billed 
with a GZ modifier, which means that these services do not meet Medicare criteria for coverage. Therefore, we 
decided that the Plan does not have to pay for SelectMDx testing billed with code 81479-GZ for date of service 
June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has tried and failed physical 
therapy and occupational therapy with modalities of static bracing as well as Botox injections. The Plan denied 
your request. The Plan says this device is unproven and not medically necessary due to insufficient evidence of 
safety and efficacy. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro Motion G represents the 
enrollees best opportunity for regaining meaningful use for their right upper limb and has been deemed 
medically necessary. The Plan denied your request. The Plan says the MyoPro orthosis is considered 
experimental and investigational when used to help restore function to arms and hands paralyzed or weakened 
by CVA stroke, brachial plexus injury, cerebral palsy or any other neurological or neuromuscular disease or 
injury. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) testing provided 
on April 29, 2022, billed with codes 87481, 87500, 87640, 87641, 87651, 87653 and 87798. 
 
You asked the Plan to pay for urine PCR testing. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this testing was not medically 
necessary and was not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of urine PCR testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) testing provided on April 29, 2022, billed with codes 87481, 87500, 87640, 87641, 87651, 87653 and 
87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99233 and 99232 billed for dates of service May 27, 
2022, and May 28, 2022. 
 
You asked the Plan to pay for codes 99233 and 99232. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says payment for these codes is bundled into other 
codes 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. In this case, we have confirmed that codes 
99233 and 99232 are column II codes to column I codes 99223 and 99233 with a modifier indicator of 0. The column II codes are 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 codes 99233 and 99232 billed for dates 
of service May 27, 2022, and May 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673 RT&LT) provided to the enrollee on March 18, 2022. 
 
You asked the Plan to pay for the services. You say that you do not agree with the denial for place of treatment. 
The Plan denied your request. The Plan says since the place of service is an ambulatory surgical center, the 
segmental gradient pressure pneumatic appliance, half leg (E0673 RT&LT) is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the services was used in a SNF or hospital. Therefore, we decided that the Plan does not 
have to pay for a segmental gradient pressure pneumatic appliance, half leg (E0673 RT&LT) provided to the 
enrollee on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99213) provided on February 21, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid diagnosis 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 find that CPT code 99213 is not supported in the medical record. Specifically, S61.212S is a sequala code 
and is not a valid primary diagnosis code. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay 
for physician services (99213) provided on February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee has respiratory failure and has tried 
other equipment and was unsuccessful. 
 The Plan denied your request. The Plan says the records do not show that the enrollee meets the Medicare 
criteria for lung devices. 
 
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 requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has obesity hypoventilation syndrome without known lung disease. The record provided is insufficient to establish the presence of restrictive thoracic disease.  
Notwithstanding that the record does not indicate the presence of an enumerated condition for which coverage 
s available, the record indicates that the provider intended to order BiPAP. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The plan has indicated coverage for such a device is available upon request. The elements of the 
coverage criteria are not satisfied. The requested service cannot be 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services on June 2, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for laboratory services.  
 
 
 
 
 
 
 
 
 You have been asked to pay a $15 copayment for laboratory services. This item/service falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for laboratory services on June 2, 2022.