Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve authorization for transcatheter tricuspid valve repair 
(TTVR) and inpatient admission. 
 
You asked the Plan to pre-approve authorization for TTVR and inpatient admission. 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 authorization for TTVR and inpatient 
admission. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found based on current clinical guidelines, there are insufficient 
randomized clinical data at this time to support the use of TTVR in this setting. As such, it would not be considered medically appropriate and necessary in this enrollee's management. At the current time, TTVR is 
not considered to be medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of authorization for TTVR and inpatient admission have not been met. Therefore, 
we decided that the Plan does not have to pre-approve authorization for transcatheter tricuspid valve repair 
(TTVR) and inpatient admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 1, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says an inpatient hospital admission 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 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 this inpatient admission was not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 June 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve a VIA Disc allograft intervertebral disc augmentation 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 a VIA Disc allograft intervertebral disc 
augmentation procedure. 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 compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested VIA Disc allograft intervertebral disc augmentation procedure, in this case, is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a VIA Disc allograft intervertebral disc augmentation procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc 
augmentation procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64415-RT) provided on October 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed modifier 
does not match the 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 payment for CPT code 64415-RT is not supported in the medical record. Specifically, code 64415 
was billed with modifier RT. However, the claim was billed with an unspecified diagnosis code. As such, the 
laterality of the diagnosis code does not match the laterality of the appended modifier. 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 (64415-RT) provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88368, 88369, and 88377 provided on 
October 25, 2022. 
 
You asked the Plan to pay for procedure codes 88368, 88369, and 88377. You say that the medical records 
support the use of modifier 59 billed with codes 88368, 88369, and 88377. The Plan denied your request. The 
Plan says the medical records do not support the use of modifier 59 billed with codes 88368, 88369, and 88377. 
 
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 88368, 88369, and 88377 are column II codes to column I codes 
81405, 81403, 81347, 81334, and 81176; however, 88368, 88369, and 88377 were billed with a modifier.  
 
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 procedure codes 88368, 88369, and 88377. Our reviewer 
says that the medical records do not support the use of modifier 59 billed with codes 88368, 88369, and 88377. 
Our reviewer found although these procedures were reported with modifier -59 distinct procedural service, the 
laboratory report does not support these procedures as separate distinct procedures from the billed procedures 
codes 81405, 81403, 81347, 81334 and 81176 and therefore, would not be covered separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 88368, 88369, and 88377 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 88368, 88369, and 88377 provided on October 
25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99243 billed for date of service February 16, 
2022. 
 
You asked the Plan to pay for procedure code 99243. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99243 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99243 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99243 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99243 billed for date of service February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services identified with procedure 
codes 99204, 74230, 72040, 70100, 70310, and 74240 provided on October 21, 2022. 
 
You asked the Plan to pay for the office visit and related services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable 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 codes 99204, 74230, 72040, 70100, 70310, and 74240 are not supported in the medical 
record. Specifically, the documentation shows that these services were billed with a place of service 11 (office). 
The documentation shows that these services were provided in a mobile unit setting. This means the claim is 
not payable as billed. Based on this information, we decided that Medicare rules for coverage of the office visit 
and related services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit and related services identified with procedure codes 99204, 74230, 72040, 70100, 70310, and 74240 
provided on October 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says SNF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation does not show acute clinical or functional changes. 
There is no documentation to show that the enrollee requires daily skilled services on an inpatient basis in a 
skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76604, 99291, 99292 rendered on July 23, 
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 records do not support the services 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, the CPT Code Manual definition of the denied codes is: 
 
CPT 76604: 
 
Ultrasound, chest (includes mediastinum), real time with image documentation 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes CPT 99292: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 
minutes (List separately in addition to code for primary service) 
 
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 medical records provided 
does not include sufficient documentation to validate that the denied codes were actually rendered in this case. 
The services cannot be verified. 
 
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 procedure codes 76604, 99291, 99292 rendered on July 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Allergen profile, basic food (82785, 86003) provided 
November 9, 2022. 
 
You asked the Plan to pay for the food allergy testing. You say that please reconsider the denial of CPT 82785 
and 86003. Review attached medical records and waiver of liability and reprocess the claim for payment. The 
Plan denied your request. The Plan says under Medicare guidelines, the food allergy testing provided does not 
meet the requirements for approval. 
 
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 food allergy testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Allergen profile, basic food (82785, 86003) provided November 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 16, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 laboratory services rendered on 
December 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 30, 2022, to 
February 8, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that specific data elements are required on the claim for the 
claim to be payable. A Plan of Care must be provided with the documentation submitted. 
 
We reviewed the file and the Medicare rules. We find that the documentation did not include a Plan of Care for 
the dates of service billed. 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 January 30, 2022, to February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hematology profile (81455) provided on September 2, 
2022. 
 
You asked the Plan to pay for the Hematology profile. You say that the treating physician determined this 
testing to be medically necessary. The Plan denied your request. The Plan says a review of the medical 
literature and clinical practice guidelines does not support the clinical utility of broad genomic profiling for a 
hematological malignancy work-up. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are met. 
 
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 Hematology profile. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that based on the medical records 
provided there is no documentation that the NGS provided with date of service September 2, 2022, meets all of 
the criteria for medically reasonable and necessary for the enrollee. Provided records in this case do not 
document that the enrollee had either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV 
cancer and had not been previously tested with the same test using NGS for the same cancer genetic content, 
and that the enrollee had decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
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 Hematology profile have not been met. Therefore, we decided that the Plan 
does not have to pay for the Hematology profile (81455) provided on September 2, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided March 3, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that revenue codes billed with an inappropriate CPT/HCPCS code on 
claims for episodes beginning on or after January 1, 2008, must report a 0023 revenue code line on which the 
first four positions of the HIPPS code match the code submitted on the request for anticipated payment (RAP). 
 
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 states that revenue codes billed with an inappropriate CPT/HCPCS 
code on claims for episodes beginning on or after January 1, 2008, must report a 0023 revenue code line on 
which the first four positions of the Health Insurance Prospective Payment System (HIPPS) code match the 
code submitted on the request for anticipated payment (RAP). RAPs are no longer required for services 
provided after January 1, 2022. This means the Plans argument for denial is invalid. No other denial rationale 
was provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the 
home health services provided March 3, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 8, 2022, 
through January 10, 2022, and billed with diagnosis code J96.01. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis J96.01 acute respiratory failure with hypoxia is supported by the records. The Plan denied 
your request. The Plan says the documentation submitted does not support secondary diagnosis of J96.01. 
 
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 secondary diagnosis code J96.01-acute respiratory 
failure with hypoxia. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the secondary 
diagnosis of J96.01 acute respiratory failure with hypoxia. Our physician reviewer found the member presented 
with shortness of breath and was treated for unspecified viral pneumonia in the setting of chronic obstructive 
pulmonary disease (COPD). There is no evidence that the member had acute respiratory failure or required 
ventilatory assistance. The member uses oxygen at baseline. As such secondary diagnosis code-J96.01-acute 
respiratory failure with hypoxia remains unsupported.  
 
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 January 8, 2022, through January 10, 2022, and billed with diagnosis 
code J96.01.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services coded A0428 and A0425 provided on 
November 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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 codes A0428 and A0425 are not supported in the medical record. Specifically, these services 
were billed with a primary diagnosis of I26.01 (septic pulmonary embolism with acute cor pulmonale). This 
diagnosis has a "code first" note. This means this diagnosis is not acceptable as a primary diagnosis. The claim 
is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance services coded A0428 and A0425 provided on November 19, 2022.