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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 30, 
2022, to June 2, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee had an approved 
authorization for the inpatient admission. The Plan denied your request. The Plan says the enrollee did not meet 
inpatient criteria for admission. 
 
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 that the clinical documentation does not support that at the time of inpatient 
admission it was reasonable for the admitting physician to expect that the patient'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 from May 30, 2022, to June 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
(87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on September 28, 2022. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing should be billed with a single 
panel code. The Plan denied your request. The Plan says this testing was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a 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 respiratory PCR panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) 
provided on September 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Stabilink interlaminar stabilization procedure. 
 
You asked the Plan to pre-approve Stabilink procedure. You say that this is the most effective treatment 
possible. The Plan denied your request. The Plan says there is insufficient evidence of the efficacy of this 
procedure. 
 
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 Stabilink procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Stabilink interspinous device procedure is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stabilink procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Stabilink interlaminar stabilization procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the requested testing does not meet the 
requirements for approval. The genetic test requested is not approved by MolDX Technical Assessment. 
 
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. The records show that the requested test is not an approved test as it 
has not completed the registration and technical assessment process to meet Medicares criteria for coverage. 
Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve genetic testing (81479).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. 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 30, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on September 19, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and were reported 
correctly. The Plan denied your request. The Plan says that the code used to report these services is not 
supported in the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the medical records support that 
drugs from 19 drug classes were tested in this case. Based on this information, we decided that Medicare rules 
for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on September 19, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on October 5, 2022. 
 
You asked the Plan to pay for the imaging services. 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 the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services have not been met. Specifically, this claim was billed with the office setting 
POS code (11). The records do not support that the imaging services were provided in a office setting. 
Therefore, we decided that the Plan does not have to pay for the imaging services provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99214 billed for date of service March 25, 2022. 
 
You asked the Plan to pay for code 99214. You say that this code was billed correctly. The Plan denied your 
request. The Plan says code 99214 is not supported in the medical record and has been downgraded to code 
99213. , Per the documentation, the member presented with 2 self-limited or minor problems (possible urinary 
tract infection and complaint of abnormal vaginal discharge). This supports a low level of decision making. 
 
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 99214 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires a detailed history; a detailed examination; medical 
decision-making of moderate complexity. 
 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 code 99214. Our reviewer says that code 99214 is not 
supported in the medical record. Our reviewer found the enrollee was a then 90-year-old female with a history 
of coronary artery disease, diabetes mellitus, stroke, hypertension, hyperlipidemia, gastroesophageal reflux 
disease, and indwelling Foley catheter and pessary who was evaluated on for a brown vaginal discharge and 
possible urinary tract infection. She had an exam and the vaginal swab and urine culture were sent and she was 
placed on antibiotics. These records support a low level of decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99214 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99214 billed for date of service March 25, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87150, 87798, 87481 and 87801) provided on 
December 29, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that these services were not billed in 
accordance with Medicare guidelines. 
 
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 not cited the rule used for this denial. We are unable to 
locate this rule in a determination which applies to the state at issue. The Plan has failed to substantiate their 
denial in this case. Therefore, we decided that the Plan has to pay for laboratory services (87150, 87798, 87481 
and 87801) provided on December 29, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this is medically necessary and supported by strong 
science. The Plan denied your request. The Plan says the enrollee has previous lumbar fusion and has sacroiliac 
(SI) problems. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Effexor XR. 
 
You asked the Plan to pre-approve Effexor XR. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 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 pre-approve Effexor XR.  
 
Benefits for Effexor XR may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from April 20, 2021, to May 13, 2021. 
 
You asked the Plan to pay for the home health services. You say that this claim was billed but you were later 
told the claim should have gone elsewhere. The Plan denied your request. The Plan says that this claim was 
sent to them in error. 
 
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 provided a limited explanation as to why this claim was 
denied.  It appears that the Plan's sole denial rationale is that the claim should have gone to the Plan's 
designated home health payment vendor for processing instead of the Plan's main claim processing center.  The 
Plan has provided absolutely no documentation showing that you are required to send this claim to another 
vendor.  The Plan has provided no evidence that it has tried to forward the claim to the correct place.  Since it 
appears that the Plan's home health claim vendor is an affiliated entity of the Plan, the Plan should have 
mechanisms in place to properly route misfiled claims.  It does not appear that the Plan has made any efforts to 
either correct the error or to assist your organization in correcting the error.  The burden is on the Plan to show 
why its denial is appropriate.  Because of the aforementioned reasons, we find that the Plan has not met its 
burden. Therefore, we decided that the Plan has to pay for home health services provided from April 20, 2021, 
to May 13, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) provided on 
October 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that before you went to this 
provider, you were told that they were in network. You were not told that some doctors took the Plan, and some 
did not. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 integrated biopsychosocial assessment (90791) 
provided on October 4, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0667) and segmental pneumatic appliance for use with 
pneumatic compressor, trunk (E0656) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor, a full leg segmental pneumatic appliance, and a 
trunk segmental pneumatic appliance to be provided by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor (E0652), segmental pneumatic appliance for use with pneumatic compressor, full leg 
(E0667) and segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) to be provided 
by an out-of-network (OON) provider.
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 power wheelchair. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the records show the enrollee can walk. The 
enrollee is requesting a scooter for use outdoors. 
 
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 power wheelchair. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to Medicare, a power mobility device is medically necessary if an enrollee 
has a mobility limitation that significantly impairs her ability to participate in one or more mobility-related 
activities of daily living. The mobility limitation cannot be sufficiently and safely resolved by the use of a fitted 
cane or walker, or the beneficiary does not have sufficient upper extremity function to self-propel an optimally 
configured manual wheelchair. Additionally, if any POV or PWC is only for use outside the home, it is denied 
as noncovered. The enrollee must also have the mental and physical capabilities to safely operate the power 
wheelchair and the home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the PWC. In this case, the documentation does not indicate the enrollee requires a power mobility 
device to accomplish mobility related self-care tasks in the home. Additionally, there is no indication she is 
unable to use an alternative assistive device. 
 
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 power wheelchair 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw  
(CPT 70100), a swallowing function x-ray (CPT 74230), diagnostic radiology procedures of the head and neck  
(CPT 70310) and an upper gastrointestinal tract x-ray (CPT 74240) provided on November 1, 2022. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a swallowing 
function x-ray (CPT 74230), diagnostic radiology procedures of the head and neck (CPT 70310) and an upper 
gastrointestinal tract x-ray (CPT 74240). You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were performed at a nursing home (via mobile van/portable x-ray), 
which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a swallowing function x-ray (CPT 
74230), diagnostic radiology procedures of the head and neck (CPT 70310) and an upper gastrointestinal tract 
x-ray (CPT 74240) have not been met. Therefore, we decided that the Plan does not have to pay for a 
neck/spine x-ray (Current Procedural Terminology (CPT) code 72040), an x-ray of jaw (CPT 70100), a 
swallowing function x-ray (CPT 74230), diagnostic radiology procedures of the head and neck (CPT 70310) 
and an upper gastrointestinal tract x-ray (CPT 74240) provided on November 1, 2022.