Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee's medical needs are being met in the current acute setting, LTACH admission would add no additional 
services. 
 
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 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 health 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 long term acute care hospital (LTACH) services.
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 
December 19, 2021, to March 7, 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 payment of some of these services are not supported. 
 
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 not supported by the medical records. Our reviewer found that the denied charges for denial code 
B ($14,782) does not meet the criteria, as these items (chest wall manipulation; insert indwelling bladder cath; 
office/op visit; orthopedic support procedure; us guide vascular access) were not found in medical record to 
verify as performed. The pos airway pressure cpap denied correctly, as this charge was included in "vent 
management" payment. 
 
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 inpatient hospital services provided to the enrollee from December 19, 2021, to March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transport chair (E1038) provided to the enrollee on 
February 18, 2022. 
 
You asked the Plan to pay for the chair. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no evidence of a mobility limitation. 
 
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 chair. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record from the ordering provider does not address the enrollee's functional status. There was no 
neurological or functional status evaluation. It is not reasonable to extrapolate from the available information. 
 
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 chair have not been met. Therefore, we decided that the Plan does not have 
to pay for a transport chair (E1038) provided to the enrollee on February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for gauze supplies provided on August 23, 2022. 
 
You asked the Plan to pay for the gauze supplies. You say that these supplies are separately payable because 
they were dispensed to the patient for their own use, not for use during a procedure. The Plan denied your 
request. The Plan says that these supplies are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services with a status indicator of P are 
not separately payable under the Physician fee schedule. If the item or service is covered as incident to a 
physician service and is provided on the same day as a physician service, payment for it is bundled into the 
payment for the physician service to which it is incident (an example is an elastic bandage furnished by a 
physician incident to a physician service). If the item or service is covered as other than incident to a physician 
service, it is excluded from the fee schedule (for example, colostomy supplies) and is paid under other payment 
provisions. 
 
In this case, we agree that the gauze supplies provided have a status indicator of P on the Physician Fee 
schedule and would therefore not be separately payable under that fee schedule. However, according to the case 
file that the Plan sent to us, the only items/service billed on this date are the gauze supplies at issue.  There is 
no evidence that these items were provided incident to a physician service.  According to Medicare rules, these 
items are therefore potentially payable under the Durable Medical Equipment, Prosthetics, Orthotics, and 
Supplies (DMEPOS) fee schedule.  The Plan has failed to provide any evidence showing that these supplies 
would NOT be payable under the DMEPOS fee schedule.  Further, it also appears that the Plan is alleging that 
the gauze supplies were dispensed prior to the written order for the items.  This is not corroborated in the 
documentation that the Plan sent to us.  The records show that the gauze supplies at issue were prescribed and 
ordered on August 22, 2022 (the same day of shipment), and the supplies were delivered on the following day.  
These are allowable dates for the order process. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the gauze supplies have been met. Therefore, we decided that the Plan has to pay for gauze 
supplies 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 16, 2022, billed with 
multiple procedure codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing provided is not experimental 
and should be covered. The Plan denied your request. The Plan says an appeal determination was not made as 
the timeframe was missed. 
 
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 
June 16, 2022, billed with multiple procedure codes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on August 24, 2022, and 
August 25, 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 this is only covered under Part D. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on August 24, 2022, and August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided July 23, 
2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you do have supporting the 
medical necessity of the device it was discussed with the enrollee's the need for postoperative deep vein 
thrombosis (DVT) prophylaxis to prevent DVT and pulmonary edema. The Plan denied your request. The Plan 
says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
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 July 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that these are medically necessary services that should 
be paid. 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 provided on July 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
20, 2022. 
 
You asked the Plan to pay for the ED services. You say that your coding team corrected the diagnosis, and this 
claim should now be payable. The Plan denied your request. The Plan says an unspecified side diagnosis code 
was used when the side should be identified. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. Unspecified side codes should only be 
used when the information is not sufficient to determine the side the condition occurs on. 
 
We looked at the file and Medicare rules. This is a claim for ED services using the diagnosis code S22.39XA, 
defined as fracture of one rib, unspecified side, initial encounter for closed fracture. It would be expected that the treating provider would identify the side the fracture occurred on. As such, using the unspecified side code 
would not be appropriate. Based on this information, we decided that Medicare rules for coverage of the ED 
services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that transferring to a LTACH will care for all 
the enrollee's needs and provide medically appropriate level of care and optimal opportunity for a successful 
outcome. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot 
be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a 
therapeutic advantage. 
 
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 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 health 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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on July 27, 
2022, to July 31, 2022. 
 
You asked the Plan to pay for the SNF services. You say that you had not yet determined the Health Insurance 
Prospective Payment System (HIPPS) code when authorization was requested. The Plan denied your request. 
The Plan says the HIPPS code that you billed was not authorized. 
 
Medicare rules say that plans require prior authorization.  The contract in this case requires prior authorization 
for SNF services.  In this case, the Plan issued an authorization for SNF services that was specific to HIPPS 
code KDXD.  You billed with HIPPS code JDUDI. You did not request authorization for this specific HIPPS 
code, so the Plan did not authorize this particular HIPPS code.   
 
Because The Plan did not pre-approve the SNF services at issue at the HIPPS code you actually billed, we 
found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the 
Plan does not have to pay for skilled nursing facility (SNF) services provided on July 27, 2022, to July 31, 
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for 
admission to an LTACH. 
 
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. The Plan has approved ongoing care 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided June 29, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. You are not contracted 
with the facility or the prescribing physician and do not receive payment from either provider. The Plan denied 
your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
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 (E0675) and segmental pneumatic appliances (E0673) provided June 
29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional 8 units of procedure code 87798 provided to 
the enrollee on August 31, 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 the maximum allowed units have already been approved. 
 
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 87798 is "Infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique, each organism." 
 
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 in this case there was no specific 
clinical rationale for the additional units requested. The records did not support that these 8 units were 
medically reasonable and necessary. 
 
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 an additional 8 units of procedure code 87798 provided to the enrollee on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 73080 billed on date of service July 22, 2022. 
 
You asked the Plan to pay for code 73080. You say that this is a covered code and it was medically necessary. 
The Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. 
 
In this case, the code in dispute (73080) is an STV-packaged service because it has a status indicator of Q1 in 
Addendum B- Outpatient Prospective Payment System (OPPS).  Code 73080 was billed on the same claim as 
code 99283. Code 99283 has a status indicator of V.  This means that code 73080 is not separately payable in this scenario. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 73080 have not been met. Therefore, we decided that the Plan does not have to pay for code 
73080 billed on date of service July 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93005, 72125, 73060, 73080, and 73030 billed for date 
of service September 1, 2022. 
 
You asked the Plan to pay for codes 93005, 72125, 73060, 73080, and 73030. You say that these services were 
medically necessary and should be paid. The Plan denied your request. The Plan says these codes are not 
separately payable. 
 
The Plan must follow Medicare rules. The rules state that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. You can find this rule at Centers for Medicare and Medicaid Services, 
Internet-Only Publication 100-04, Medicare Claims Processing Manual Chapter 4, Section 10.4.C.2.  
 
In this case, codes 93005, 73060, 73080, 73030 are STV-packaged services because they have a status 
indicator of Q1 in Addendum B- Outpatient Prospective Payment System (OPPS).  These codes were billed on 
the same claim as code 99285. Code 99285 has a status indicator of V.  This means that codes 93005, 73060, 
73080, and 73030 are not separately payable in this scenario. 
 
In relation to code 72125, the rules say that for services that have a status indicator of Q3, the payment for 
these services is considered part of the composite Ambulatory Payment Classification (APC) rate, so no 
separate payment is made. This code has a status indicator of Q3, so it is included in the APC payment and no 
separate payment is due. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 93005, 72125, 73060, 73080, and 73030 have not been met. Therefore, we decided that the 
Plan does not have to pay for codes 93005, 72125, 73060, 73080, and 73030 billed for date of service 
September 1, 2022.