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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee should be transferred to 
LTACH for the continuation of care for complex medical needs that require ongoing acute care. The Plan 
denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as an acute rehabilitation facility, skilled nursing facility, nursing facility, 
outpatient setting, or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care hospital services that can safely be administered at the current facility until 
more appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156) and direct 
skilled nursing services of a registered nurse (RN) (G0299). 
 
You asked the Plan to pre-approve HHA and RN services. The Plan denied your request. The Plan says the 
clinical information did not indicate that the enrollee requires skilled nursing care at home. 
 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 HHA and RN services. Our reviewer 
says that home health services are not shown to be medically necessary or reasonable. Our physician reviewer 
found the enrollee does not have documented skilled nursing needs. Our reviewer also found that the enrollee 
does not have documented skilled therapy needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HHA and RN services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health aide (HHA) services (G0156) and direct skilled nursing services of a 
registered nurse (RN) (G0299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 35221 billed for date of service April 20, 
2022. 
 
You asked the Plan to pay for procedure code 35221. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 35221 is bundled into payment for code 48150. 
 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 35221 
is a column II code to column I code 48150. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 35221 billed for date of service April 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.  
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 76705 billed for date of service June 22, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine (72148). We decided that the Plan 
does not have to pre-approve an MRI of the pelvis (72195).  
 
You asked the Plan to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148) and MRI 
of the pelvis (72195). The Plan says that an MRI is not medically necessary. 
 
We decided that the Plan has to pre-approve an MRI of the lumbar spine (72148).  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
 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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is reasonable and necessary. Our physician reviewer found there 
is an MRI report for the lumbar spine in records dated October 11, 2021. During the encounter on February 4, 
2022, despite the report of the 2021 scan, the clinician recommended a repeat study due to symptoms. Based on 
the history and the stated plan of workup, this requested MRI of the lumbar spine should be approved for a 
patient with prior lumbar fusion, abdominal wall abscess, and fistula. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve an MRI of the lumbar spine (72148).  
 
We also decided that the Plan does not have to pre-approve an MRI of the pelvis (72195). 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the pelvis (72195). Our 
reviewer says that an MRI of the pelvis (72195) is not reasonable and necessary. Our physician reviewer found 
an MRI of the pelvis was done and there is a report in the chart dated March 3, 2022. Our reviewer also found 
that there is no discussion found indicating this study needs to be repeated, as no significant findings were 
noted on that scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the pelvis (72195) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the pelvis (72195). 
 
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 pathology services (88361, 88312, 88112 and 88305) billed 
for date of service March 10, 2022. 
 
You asked the Plan to pay for pathology services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says these services were not billed with a 
necessary modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88361, 88312, 88112 and 88305 are physician pathology services which have both 
professional components (PC) and technical components. These services were not billed with modifier 26 to 
indicate that only the professional component payment is requested. This means that payment is requested for 
both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
outpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology 
services (88361, 88312, 88112 and 88305) billed for date of service March 10, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve additional home health occupational therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that there is nobody to help you. The Plan 
denied your request. The Plan says that you do not meet the Medicare criteria for the requested home health 
care. 
 
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 you meet the Medicare criteria for the 3 requested additional home health visits. Our physician 
reviewer found you have not been able to transfer in the bathroom and have not trialed tub transfer or bench 
transfers, thus there are reasonable home health occupational therapy goals that are not yet met. 3 additional 
home health occupational therapy visits are 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 home health services have been met. Therefore, we decided that the Plan has to 
pre-approve additional home health occupational therapy visits.  
 
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 pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of an IRF admission. 
 
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 that the clinical documentation shows that although you have an IRF compliant 
diagnosis of a hip fracture and evaluating therapists recommend intense therapy, you do not have documented 
active comorbidities that would require close medical monitoring on an inpatient basis during rehabilitation.  
Therefore, you do not meet criteria for coverage of an IRF admission.   
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 15, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was not 
billed the appropriate modifier. 
 
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 the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, the professional component must be billed with modifier -
26 for payment to be considered. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote pacemaker monitoring provided on March 15, 2022. 
 
You asked the Plan to pay for remote pacemaker monitoring. You say that remote pacemaker monitoring was 
medically necessary. The Plan denied your request. The Plan says remote pacemaker monitoring was not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of remote pacemaker monitoring provided on March 15, 2022 have been met. Specifically, no medical records were provided. Therefore, we 
decided that the Plan does not have to pay for remote pacemaker monitoring provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management rendered on April 
14, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 hospital discharge 
day management rendered on April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 26, 2021, and billed 
with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194, and 
81309. 
 
You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
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 genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on October 
26, 2021, and billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 
81401, 81194, and 81309.
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 enrollee is stable for transfer to 
LTACH and the service is medically necessary. The Plan denied your request. The Plan says the LTACH is not 
medically necessary, and the enrollee's can be met at a lower level of care such as a skilled nursing facility 
(SNF) or at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with septic shock, acute 
respiratory failure, COVID-19 infection, acute kidney injury, deep vein thrombosis (DVT), anemia, and 
pneumonia requiring intubation, antibiotics, steroids, vasopressors. She also required debridement, antibiotics, 
and wound care for cellulitis/osteomyelitis on chronic ulcers on legs. The enrollee is improving but still needs a 
more stable feeding source and should only require short-term additional acute care hospital services that can 
safely be administered at the current facility until more appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current 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 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 infectious agent detection by nucleic acid (DNA or RNA) 
3-5 targets (87631) provided May 12, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that based on the references mentioned, the 
denial reason is incorrect. The Plan denied your request. The Plan says The submitted documentation indicates 
more than five (5) targets. There is a more appropriate code to describe the services provided. Multiplex PCR 
respiratory viral panels of 6 or more pathogens are non-covered. 
 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 87631 is infectious agent detection by nucleic acid (DNA 
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza 
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.  
 
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 laboratory services. Our reviewer says that the Medicare 
criteria for coverage is not supported in the medical records. Our reviewer found procedure code 87631 is not 
documented in the documentation. There is a more appropriate code that can be billed to capture all the correct 
array. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) 3-5 targets (87631) 
provided May 12, 2022.
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 November 6, 
2021, to December 3, 2021. 
 
You asked the Plan to pay for procedure code S9328. You say that the code is payable. 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code S9328 billed for date of service November 6, 2021, to December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 home tests purchased on 
June 10, 2022. 
 
You asked the Plan to pay for OTC COVID-19 tests. You say that you have Medicare coverage and this test 
should be covered. The Plan denied your request. The Plan says these services are not covered by your Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and OTC 
COVID-19 tests is an OTC item. The Plan does not provide reimbursement for OTC items purchased in a store, 
and although Medicare provided coverage of COVID-19 tests on the date in question, the participating provider 
needed to bill Medicare directly for this service. The Medicare Advantage Plan is not responsible for coverage of this test. Therefore, we decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 
home tests purchased on June 10, 2022.