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

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
13, 2022, to October 7, 2022. 
 
You asked the Plan to pay for procedure code S9328. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 13, 2022, to October 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had renal failure, bowel/bladder incontinence, 
multiple surgeries he got infections from, stents in heart, pacemaker put in, and never got the proper 
rehabilitation that was supposed to get at the nursing home and is completely dependent on others to do basic 
daily living tasks. The Plan denied your request. The Plan says the documentation fails to indicate that you 
require rehabilitation and physician evaluation or treatment at least 3 times per week or the need for availability 
of rehabilitation nursing 24 hours 7 days a week, services can be met at a lower level of care, at a skilled 
nursing facility or home with home health care.  
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
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 
information we have about your condition the enrollee does not meet all the requirements; care can be provided 
in the current inpatient hospital. 
 
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 current 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 the inpatient hospital services provided on February 17, 
2022, to February 25, 2022, 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 the 
physicians judgement should be considered precise. The Plan denied your request. The Plan says there is 
insufficient evidence to validate the diagnosis. 
 
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 N17.0, defined as acute kidney failure with tubular 
necrosis. 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 physician reviewer found that the enrollee presented to the hospital with chest pain. 
The enrollee was admitted for hyperkalemia and acute on chronic anemia with suspected gastrointestinal bleed. 
Acute tubular necrosis (ATN) is the most common cause of acute kidney injury. The history, physical 
examination, and laboratory findings, especially the renal ultrasonogram and the urinalysis, are particularly 
helpful in identifying the cause of ATN. In this case, there was no clinical or laboratory evidence of acute renal 
failure with tubular necrosis. As such, the clinical evidence did not support the diagnosis.  
 
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 the inpatient hospital services provided on February 17, 2022, to February 25, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service November 9, 
2022. 
 You asked the Plan to pay for procedure code 99152. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99152 is bundled into payment for code 45385. 
 
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 99152 
is a column II code to column I code 45385. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 99152 billed for date of service November 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation to get 
better function through physical and occupational therapy. The Plan denied your request. The Plan says the 
records do not support the services requested; services needed are assistance with self-care. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80048, 36415, P9604) provided on 
October 28, 2021. 
 
You asked the Plan to pay for laboratory services. You say that you could not submit this claim within 12 
months as the office was understaffed. The Plan denied your request. The Plan says this claim was not filed 
timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for laboratory services was not filed until November 7, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for laboratory services (80048, 36415, P9604) provided on October 
28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate and Influx Fibrant bone graft 
services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested bone graft is not the standard of care and bone marrow aspirate is unproven. 
 
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 the requested services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis of the lumbar region with neurogenic 
claudication.  There is no specific indication provided to support the request for bone marrow aspirate for the approved 
surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone 
marrow aspirate for this enrollees medical condition. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception.  
There is limited published, large-scale, long-term peer-reviewed literature that shows this requested allograft to 
be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this 
request has beneficial outcomes compared with conventional treatment. Therefore, the requested bone marrow 
aspirate and Influx Fibrant bone graft services are 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate and Influx Fibrant bone graft services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on May 16, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit rendered on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this destination exceeds 50 miles per one-way trip. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers routine transportation up to 50 miles of driving distance per one-way trip.  
 
We looked at your request, the records in the case file, and the rules. The requested destination is more than 50 
miles of driving distance per one-way trip. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a motorized scooter. You say that you need the scooter to get around with 
the ramp that you have at home. The Plan denied your request. The Plan says the requested group-1 powered 
wheelchair is inadequate to meet your needs. 
 
The Plan follows Medicare rules. 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.  
 
 The file shows that you have difficulty moving around and you have weak muscles. The records show that an 
in-home evaluation done on February 8, 2023, and March 10, 2023, confirms that a group 1 wheelchair would 
not meet all your medical needs. Please note, that a group 3 powered wheelchair with special features has been 
approved by the Plan and it can be modified as your condition gets worse. 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 a 
power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 51785, 95861, and 95870 billed for date of 
service July 13, 2022. 
 
You asked the Plan to pay for the billed services. You say that the benefits of intraoperative monitoring 
outweigh the costs. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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 51785, 95861, and 95870 is not supported and not separately reportable in this case. 
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 51785, 95861, and 95870 
billed for date of service July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services billed with code 64400 for 
November 18, 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 was not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that procedure code 64400 is limited to specific diagnosis 
codes that support medical necessity only. 
 
We looked at the file and Medicare rules. The file shows that code 64400 was not billed with a diagnosis code 
listed as supporting medical necessity. 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 pain 
management services billed with code 64400 for November 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 9 home health skilled nursing services. 
 You asked the Plan to pre-approve home health services. You say that you feel that additional skilled nursing 
visits are needed. 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 member is 
a 74-year-old female with a medical history including Parkinson's disease, previous stroke, hypertension and 
dementia who has been receiving home health skilled nursing services. The documentation indicates she has 
been medically stable and without any complications. There is no indication that the member has a feeding 
tube, parenteral medications or complex wound care issues. There is no indication that the member had any 
recent medication changes or hospitalizations. There has not been a recent decline in function and the member 
has been medically stable. 
 
In this case, the documentation doesnt support that the member requires additional skilled nursing services to 
provide treatment that is medically necessary. The member does not require additional skilled nursing services 
to effectively provide treatment, care, and/or services in order to improve the members condition, perform a 
maintenance program to maintain the members condition and/or prevent deterioration.  The member has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  
 
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 an additional 9 home health skilled nursing services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 CDx (81479) provided on August 15, 2022. 
 
You asked the Plan to pay for Guardant360 CDx. You say that this test was medically necessary and was 
reported correctly. The Plan denied your request. The Plan says that 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. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Review of the claim shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx have 
been met. Therefore, we decided that the Plan has to pay for Guardant360 CDx (81479) provided on August 
15, 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 lab services provided on August 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and are 
supported in the medical record. 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 August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95885, 95907, 95927, 95937 and 95955 
billed for date of service October 7, 2021. 
 
You asked the Plan to pay for procedure codes 95885, 95907, 95927, 95937 and 95955. You say that the 
services at issue have been billed correctly. The Plan denied your request. The Plan says the available 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. 
 
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 95885, 95907, 95927, 95937 and 95955. 
Our reviewer says that procedure codes 95885, 95907, 95927, 95937 and 95955 do not meet criteria for 
payment. Our reviewer found the provided medical records do not describe the procedures denoted by procedure codes 95885, 95907, 95927, 95937 and 95955. 
 
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 95885, 95907, 95927, 95937 and 95955 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95885, 95907, 95927, 95937 and 
95955 billed for date of service October 7, 2021.