Persius/hicric huggingface dataset:
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three 
visits weekly to regain or maintain the enrollee's functional status. The enrollee can receive further services at a 
lower 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 acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (Current Procedural Terminology (CPT) 
code 72040-26), x-ray of jaw (CPT 70100-26), swallowing function x-ray (CPT 74230-26), and upper 
gastrointestinal tract x-ray (CPT 74240-26) provided on October 4, 2022. 
 You asked the Plan to pay for the neck/spine x-ray (CPT 72040-26), x-ray of jaw (CPT 70100-26), swallowing 
function x-ray (CPT 74230-26), and upper gastrointestinal tract x-ray (CPT 74240-26). You say that the 
services were medically necessary. The Plan denied your request. The Plan says the services do not meet the 
Medicare coverage criteria. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the neck/spine x-ray (CPT 72040-26), x-ray of jaw (CPT 70100-26), swallowing function x-ray 
(CPT 74230-26), and upper gastrointestinal tract x-ray (CPT 74240-26) have not been met. Therefore, we 
decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040-26), x-ray of jaw (CPT 70100-
26), swallowing function x-ray (CPT 74230-26), and upper gastrointestinal tract x-ray (CPT 74240-26) 
provided on October 4, 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 October 14, 
2021, through October 15, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the Emergency Department (ED) with shortness of breath and a 
productive cough. There is a history of multiple ED visits this year for exacerbation of Chronic Obstructive 
Pulmonary Disease (COPD). The enrollee received Albuterol nebulizer treatments and Prednisone in the ED 
with improvement; however, the oxygen levels desaturated with walking. The enrollee was admitted for COPD 
exacerbation. Treatment included Doxycycline and Albuterol/Atrovent medication as needed for nebulized 
breathing treatments. On the first day in the hospital, the enrollee was stable on baseline supplemental oxygen. 
The enrollee was able to walk while maintaining oxygen saturations above 90% and without dyspnea. The 
review has determined that the record did not show that at the time of the inpatient admission, the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier ED and/or 
observation care) would span two 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from October 14, 2021, through October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 billed for date of service March 25, 
2022. 
 
You asked the Plan to pay for procedure code 99220. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99220 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 99220 
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 99220 billed for date of service March 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 8, 2021, to 
September 11, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and diagnoses were reported correctly and are supported as billed. The Plan denied your request. The 
Plan says the DRG submitted on this claim is not supported in 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 hypertensive heart disease with heart failure (I11.0) 
and acute on chronic diastolic congestive heart failure (I50.33). 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 these 
diagnoses are not supported in the medical record. Our physician reviewer found that the documentation 
provided includes only a statement of heart failure with preserved ejection fraction. There is no 
echocardiogram report. In this case, there was no clinical or laboratory evidence of hypertensive heart disease 
with heart failure (I11.0) and acute on chronic diastolic congestive heart failure (I50.33). The documentation 
did not support these diagnosis codes.  
 
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 September 8, 2021, to September 11, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation services (A0428, A0425) provided on 
September 22, 2022. 
 
You asked the Plan to pay for ambulance transportation. You say that these services are not bundled into the 
hospital payment as they were provided on the date that the enrollee was discharged from the hospital and 
admitted to an alternate level of care at a different facility. The Plan denied your request. The Plan says that the 
payment for these services is included in the hospital payment and these services were not coded correctly. 
 
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 documentation to support that the services 
at issue would be considered inpatient transportation and/or included in a facility payment for any reason. 
There is no clear explanation or supporting evidence in the record which indicates that these services were not 
reported correctly. The Plan has not substantiated their denial in this case. Therefore, we decided that the Plan 
has to pay for ambulance transportation services (A0428, A0425) provided on September 22, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (75710, 37236, 37225) provided on February 18, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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. 
 
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 use of codes 75710, 
37236, and 37225, is not supported by the records provided. Our reviewer found that for code 75710, the 
documentation does not support that a separately identifiable diagnostic angiogram was performed, along with 
the intervention performed on the left superficial femoral artery. According to NCCI rules, the imaging, 
supervision, and interpretation is included in the intervention and not reported separately. Code 37236 is used 
to report an intravascular stent placed in an artery, except the lower extremities. The record states that the intervention was performed in the right SFA. There is a more specific code for this procedure. For code 37225, 
the documentation states that an angioplasty and stent placement were performed in the right SFA. There is a 
more specific code for an intervention that includes heparin, passes to break of the clot, and stent placement. 
 
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 the services (75710, 37236, 37225) provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (J3301, 20611) provided on August 30, 2022. 
 
You asked the Plan to pay for the injections. You say that this service was 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. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code J3301, & 20611 is not supported in the medical record. Specifically, the laterality of the 
diagnosis codes billed does not match the laterality modifiers for the procedure codes billed. Based on this 
information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we 
decided that the Plan does not have to pay for injections (J3301, 20611) provided on August 30, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne Liquid CDx testing provided on July 28, 2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says that insufficient information was provided from the 
appellant to determine medical necessity. 
 
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. The Plan indicates that multiple attempts were made to obtain necessary 
information from the provider. However, no evidence of these efforts was included in the file. Thus, we are 
unable to verify that the Plan made reasonable and diligent efforts to gather and forward information. 
Therefore, we decided that the Plan has to pay for the FoundationOne Liquid CDx testing 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 21, 2021, billed with 
codes 81225, 81227, 81226, 81241, 81328, 81335, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 81350, 
81479, 81223, 81408, 81291 and 81306. 
 
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 
October 21, 2021, billed with codes 81225, 81227, 81226, 81241, 81328, 81335, 81400, 81401, 81230, 81231, 
81240, 81232, 81406, 81350, 81479, 81223, 81408, 81291 and 81306.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 3 power wheelchair and accessories K0861, 
E2361, E1028, E2323, E1007, E2620, E0955, L0108, E1012, E0953, E2208, E2377, E2311, E2313 and E2607 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that you are writing to 
appeal this denial with further detailed information on the enrollee's ambulatory status. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria as the records show that the enrollee can use a walker, or a cane and the chair is mainly for mobility outside of the home and not for mobility inside the 
home as required under CMS guidelines. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. The file shows that your condition can be improved by a walker, cane or manual 
wheelchair and the chair is mainly for mobility outside of the home and not for mobility inside the home as 
required under CMS guidelines. This means that Medicare rules for coverage of a PMD have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Group 3 power wheelchair and 
accessories K0861, E2361, E1028, E2323, E1007, E2620, E0955, L0108, E1012, E0953, E2208, E2377, 
E2311, E2313 and E2607
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins provided on July 7, 2022. 
 
You asked the Plan to pay for the duplex scan of extremity veins. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says determination of how the enrollee came to the servicing 
provider is not supported. 
 
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. Review of the file shows that the documentation submitted  
does not determine how the enrollee came to the servicing provider, or whether the services are medically 
necessary. In the absence of clinical information, medical necessity and coverage cannot be determined. The 
listing of a referring provider on the claim does not satisfy the documentation criteria.  
 
 Based on this information, we decided that Medicare rules for coverage of the duplex scan of extremity veins 
have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan of extremity 
veins provided on July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 7, 2022, billed with 
codes 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81413, 81414 and 81442. 
 
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 July 7, 2022, billed with codes 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81413, 
81414 and 81442.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the power wheelchair accessory, 22 NF sealed lead acid 
battery, each (E2361) power wheelchair component, drive wheel motor, replacement only (E2368) power 
wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related 
electronics, mechanical stop switch, and fixed mounting hardware (E2321)  power wheelchair accessory, 
pneumatic drive wheel tire, any size, replacement only, each (E2381) and shock absorber for power wheelchair, 
each (E1016). 
 
You asked the Plan to pre-approve replacement wheelchair components. You say that the enrollee got this 
power overaged vehicle back in 1999 and parts are needed. There have not been any prior repairs. The Plan 
denied your request. The Plan says this power operated device which was purchased in March of 1999 and has 
exceeded reasonable useful lifetime and repairing with replacement parts is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a PMD will not be covered if the patient does not have 
mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by a 
walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
 
We looked at this the file, and Medicare rules. The provided records do not show that the enrollee has a 
mobility deficit that impairs participation in mobility related activities of daily living, or that the enrollees 
condition can be improved by a walker, cane or manual wheelchair. The records show that the current power 
operated device was purchased in March of 1999. The enrollee's current power operated device is 24 years old 
and has exceeded reasonable useful lifetime and repairing with replacement parts is not reasonable and 
necessary. The enrollee and provider should submit a request for a new appropriate wheelchair and covered 
accessories to meet the enrollee's current needs. Based on this information, we decided that Medicare rules for 
coverage of replacement wheelchair components have not been met. Therefore, we decided that the Plan does 
not have to pre-approve  the power wheelchair accessory, 22 NF sealed lead acid battery, each (E2361) power 
wheelchair component, drive wheel motor, replacement only (E2368) power wheelchair accessory, hand 
control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch, 
and fixed mounting hardware (E2321)  power wheelchair accessory, pneumatic drive wheel tire, any size, 
replacement only, each (E2381) and shock absorber for power wheelchair, each (E1016).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 15, 
2022.