Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered 
from July 29, 2022, to August 1, 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 code 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 record does not indicate a 
detailed history. There was simply reiteration of no acute events overnight and no complex decision making. 
The plan consisted primarily of referrals. 
 
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 subsequent hospital care (procedure code 99233) rendered from July 29, 2022, to August 1, 
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 August 6, 2022, 
to August 7, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary. The Plan denied your request. The Plan says the medical criteria for an inpatient admission were not 
met. 
 
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 record did not show 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 August 6, 2022, to August 7, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on October 9, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery is not valid. 
 
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 argues that the proof of delivery is not valid as the tracking number is 
not valid. However, the records contain an itemized packing slip dated October 9, 2022, with the same tracking 
number as the delivery ticket dated October 17, 2022. As such, the records support that the items at issue in this 
case were delivered. Therefore, we decided that the Plan has to pay for the electrical stimulator supplies 
provided on October 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acupuncture visit provided on September 20, 2022. 
 
You asked the Plan to pay for the acupuncture visit. You say that there was no visit on this date. The Plan 
denied your request. The Plan says records show a sign in for a visit on this date, and this exceeds the number 
of covered visits. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, only 19 routine sessions are covered per year. 
Records show the benefit for routine acupuncture was exhausted. Therefore, we decided that the Plan does not 
have to pay for an acupuncture visit provided on September 20, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory/pathology services (88361, 88312, 88305 and 88112) 
provided on December 21, 2021. 
 
You asked the Plan to pay for laboratory/pathology services. You say that these services were necessary and 
are supported in the medical records. The Plan denied your request. The Plan says that this claim was initially 
denied due to missing medical records. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no new reason for denial in this case, nor has 
the Plan provided any citation or evidence to support their denial. Medical records have been provided since 
the initial request. Therefore, we decided that the Plan has to pay for laboratory/pathology services (88361, 
88312, 88305 and 88112) provided on December 21, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you believe the enrollee needs a Skilled Nursing 
Facility to return to the enrollee's prior level of function. The Plan denied your request. The Plan says it 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 10, 2022 to June 
13, 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 this 
should be paid for. The Plan denied your request. The Plan says  a post-service, post-payment clinical 
validation audit was performed to help ensure that the diagnosis codes on the claim supported clinically. 
 
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 DRG 445. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee was treated for a bile duct blockage. There is no evidence that the enrollee had acute kidney 
failure, or that such a diagnosis affected his course of care.  As such, the billing of N17.9 is not supported.  
 
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 June 10, 2022 to June 13, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 You asked the Plan to pre-approve Gelsyn-3. You say that the requested drug is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Orthovisc or Supartz FX. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found that the provided documentation does 
not indicate the enrollee has tried and failed either of the preferred drugs. The reviewer also found that there is 
no documentation indicating that the plans required drug(s) would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 you require that are not available at 
the health care setting being offered by the Health Plan. The Health 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 17, 2022, billed with 
codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81328, 81335, 81355 
and 81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 17, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81238, 81291, 
81306, 81328, 81335, 81355 and 81407.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. You had a home ventilator previously but could not afford the co-pay. You may benefit from bilevel 
positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. This 
has not been tried and shown to fail as an outpatient. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP, and BiPAP with AVAPS may represent a lower co-pay for you. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81479) provided on November 21, 2022. 
 
You asked the Plan to pay for PrismRA testing. You say that this test was medically necessary and appropriate. 
The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81479) provided on November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0482) provided on September 14, 
2022. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed 
code is 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 G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested on the date of service in question. Based on this information, we decided that 
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services (G0482) provided on September 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed with Health Insurance 
Prospective Payment System (HIPPS) code 2BB21 provided April 29, 2021, to May 28, 2021. 
 
You asked the Plan to pay for home health services as billed. 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 the home health services are not supported in the medical record as billed. Specifically, no 
medical records were sent in to support the HIPPS billed. Based on this information, we decided that Medicare 
rules for coverage of home health services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services billed with Health Insurance Prospective Payment System 
(HIPPS) code 2BB21 provided April 29, 2021, to May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided July 12, 
2022, to August 15, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that by the enrollee's use of the unit, it 
helped reduce post-surgical complications and the need for pain medications while improving their range of 
motion. 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) provided July 12, 2022, to August 15, 2022.