Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that the member requires additional skilled nursing services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from 
January 14, 2022, to January 18, 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 that this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 supported by the medical records. Our reviewer found that the enrollee appears to have a history 
of aspiration (12/2021) and a documented diagnosis of dementia. Orders for a mechanical soft diet were placed 
on 1/12/2022 and 1/14/2022. It appears that the enrollee was not eating well (50% of dinners), and a nurse 
offered her a supplement on 1/16/2022. Together, this is sufficient evidence to show that the enrollee had 
cognitive impairment and was on a mechanically altered diet. That the enrollee may not have had an appetite or 
may not have liked the food, is irrelevant to the orders placed and care provided. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
skilled nursing facility (SNF) services provided to the enrollee from January 14, 2022, to January 18, 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 the pneumatic compression devices (E0673, E0675). 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says these items were not used inside a home. 
 
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 pneumatic compression devices was used in an ambulatory surgical center. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression devices (E0673, E0675).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from November 29, 
2021, to December 2, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records confirm the diagnosis code. You say that N17.9 should remain the primary diagnosis and you 
disagree with the decision to remove the diagnosis code. The Plan denied your request. The Plan says the 
documentation does not support diagnosis code N17.9. 
 
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 N17.9, defined as acute kidney 
failure, unspecified. 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 documentation does not support diagnosis 
code N17.9. Our physician reviewer found there was no clinical or laboratory evidence of acute kidney failure.  
 
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 from November 29, 2021, to December 2, 2021, at the DRG originally 
billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with codes 83789 and 82542 for 
date(s) of service July 12, 2022. 
 
You asked the Plan to pay for codes 83789 and 82542. You say that these services are medically necessary and 
should be paid. The Plan denied your request. The Plan says codes 83789 and 82542 are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 83789 and 82542 have not been met. Specifically, we find that the testing described by 
codes 83789 and 82542 is not separately payable. Therefore, we decided that the Plan does not have to pay for 
validity testing billed with codes 83789 and 82542 for date(s) of service July 12, 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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 the enrollee has ongoing acute medical issues and still requires acute care services 
before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that they are not 
currently receiving but that would be available at the LTACH 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for autonomic nervous system function testing (procedure code 
95923) provided on July 22, 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 95923 (1 Units) 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 95923 is "Testing of autonomic nervous system function; 
sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic 
sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential." 
 
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 records provided for review 
only consist of an electromyography/nerve conduction study report. There was no documentation provided that 
autonomic testing was ordered or rendered to the member at the time. Nor was there any documentation that such testing had been completed. 
 
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 autonomic nervous system function testing (procedure code 95923) provided on July 22, 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 you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. 
The Plan says the request for admission to an LTACH 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the Plan.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FibroSure testing (81596). 
 
You asked the Plan to pre-approve FibroSure testing. You say that this testing is medically necessary to 
provide a diagnosis for the enrollee. The Plan denied your request. The Plan says this testing is not medically 
necessary as it is still considered experimental. In addition, this test would be redundant with the other tests the 
enrollee has received. 
 
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 FibroSure testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that FibroSure testing would add to the to the results of standard 
laboratory testing and imaging already provided in this case. There is no evidence that the FibroSure testing 
would affect the decision to perform a liver biopsy. The test is not necessary to diagnosis or manage the 
enrollees condition. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FibroSure testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve FibroSure testing (81596).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491, 87496, 87511, 87529, 87532, 87563, 
87591, and 87661 billed for date of service December 9, 2021. 
 
You asked the Plan to pay for the billed services. You say that the test was used to device the best treatment 
plan. The Plan denied your request. The Plan says the services 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 find that CPT codes 87491, 87496, 87511, 87529, 87532, 87563, 87591, and 87661 are not supported in the 
medical record. The lab results provided do not show that these tests were performed. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87491, 87496, 87511, 87529, 87532, 87563, 
87591, and 87661 billed for date of service December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 11, 
2022 to July 22, 2022. 
 
You asked the Plan to pay for the SNF care. You say that you were advised to complete an appeal letter for a 
possible coding error in the system for the dates your father resided at the skilled facility. The Plan denied your 
request. The Plan says the enrollee was placed in custodial care. The Plan also says custodial care is not 
covered, and the enrollee did not meet the criteria for the SNF stay.  
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 pay for the 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 there is no evidence that the enrollee had skilled nursing needs or skilled therapy 
needs. Our reviewer also found that the enrollee appears to have been placed in the facility for custodial 
care/respite care, while their spouse was recuperating. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from July 11, 2022 to July 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on March 14, 2022, 
to March 15, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were 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 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 enrollee presented to the emergency department (ED) on March 14, 2022 with 
altered mental status after being found driving in a confused state. She was found to be hypertensive on arrival. 
The physical exam noted she was alert and oriented to person, place, and time but not situation. She had a 
normal electrocardiogram and 98 percent oxygen saturation on room air. Labs were unremarkable. The records 
do not support that, at the time of inpatient admission, the admitting physician reasonably expected that the 
enrollee's 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 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 March 14, 2022, to March 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 17, 2022, to 
May 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim denied incorrectly. 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 April 17, 2022, to May 
16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostatic arterial embolization (37243). 
 
You asked the Plan to pre-approve prostatic arterial embolization. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 prostatic arterial embolization. Our 
reviewer says that the requested service is are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that prostatic arterial embolization is considered an experimental technique to 
treat symptomatic benign prostatic hypertrophy (BPH). 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostatic arterial embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve prostatic arterial embolization (37243).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 
24, 2022. 
 
You asked the Plan to pay for procedure code 99285. The Plan denied your request. The Plan says payment for 
code 99285 is bundled into payment for code 99222. 
 
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 99285 
is a column II code to column I code 99222 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 99285 billed for date of service September 24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on October 20, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and were reported 
correctly. The Plan denied your request. The Plan says that the code used to report these services 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 services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the medical records support that 
at least 18 drug classes were tested in this case, including amphetamines, benzodiazepines, buprenorphine, 
cannabinoids (natural), cocaine, fentanyls, gabapentin (non-blood), heroin metabolite, methadone, 
methylenedioxyamphetamines, opiates, opioids and opiate analogs, oxycodone, phencyclidine, pregabalin, 
skeletal muscle relaxants, tapentadol and tramadol. Based on this information, we decided that Medicare rules 
for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on October 20, 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.